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DISEASES  OF  THE  DIGESTIVE  TRACT 


JpiSEASES  '.'!:!;;.  "^ 

OF   THE 

DIGESTIVE  TE ACT   ^ 

AND 

THEIR  TREATMENT 


A.  EVERETT  AUSTIN,  A.M.,  M.D. 

FOEMER  PROFESSOR  OF  PHYSIOLOGICAL  CHEMISTRY  AT  TUFTS  COLLEGE,  TTNXVERSITT 
OF  VIRGINIA,  AND  UNIVERSITY  OF  TEXAS;   PRESENT  ASSISTANT  PROFESSOR  OF 
CLINICAL    MEDICINE,    IN    CHARGE    OF    DIETETICS    AND    GASTROINTESTINAL 
DISEASES,    TUFTS    COLLEGE;     MEMBER    OF    AMERICAN    GASTROENTER- 
OLOGICAL  ASSOCIATION   AND  AMERICAN   SOCIETY  OF   BIOLOGICAL 
CHEMISTS;      PHYSICIAN     TO     MT.      SINAI     HOSPITAL     AND 
BERKELEY    INFIRMARY,    AND     ASSISTANT    TO     BOSTON 
DISPENSARY;     AUTHOR    OF    "MANUAL    OF    CLINI- 
CAL   CHEMISTRY,"    ETC. 


WITH  EIGHTY-FIVE  ILLUSTBATIONS,  INCLUDING 
TEN  COLOB  PLATES 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 

1916 


^1  NS 


COPYHIGHT,    1916,    BY    C.   V.    MoSBY    CoMPANY 


Press  of 

C.  V.  Mosby  Company 

St.  Louis 


PREFACE 

"Of  the  making  of  many  books  there  is  no  end,"  was  the  dictum  I 
of  Milton,  and  it  is  as  true  now  as  when  written,  or  else  why  aj 
preface,  which  seems  an  author's  justification  for  launching  another 
book  to  swell  the  multitude.  His  purpose  may  be  one  of  three — ^to 
add  something  to  human  knowledge,  to  put  in  a  pleasing  and  useful 
form  that  which  is  already  known,  or  to  promulgate  or  defend  some 
pet  theory  or  discovery  of  his  own.  My  purpose  is  largely  the  sec- 
ond: to  tell  in  a  clear  and  not  too  fulsome  fashion  the  facts  per- 
taining to  our  branch  of  internal  medicine — the  digestive  tract — 
without  trying  to  exhaust  any  feature  of  it,  whether  it  be  its  physi- 
ology or  pathology,  desirable  objects,  but  worthy  of  a  more  extensive 
volume  than  mine  can  possibly  be.  The  first  object,  though  incidental, 
will  also  be  attained  in  a  limited  degree,  for  no  one  can  relate  what 
he  has  observed  in  medicine  without  imparting  some  information 
which  is  not  known,  at  least,  to  all  physicians.  While  mankind  is 
said  to  have  had  the  same  origin,  yet  rarely  are  two  members  of 
the  human  race  exactly  alike  in  physiognomy;  similarly  a  disease 
may  present  the  same  general  features,  but  at  the  same  time  afford 
individual  differences.  It  is  only  by  our  acquaintance  with  these 
departures  from  the  normal  course  of  disease  that  we  become  well- 
rounded  authorities,  and  every  book  containing  any  portion  of  its 
author's  experience  with  pathological  or  clinical  vagaries  must  nec- 
essarily, when  consulted,  enlarge  our  own  perspective. 

In  this  work  the  didactic  method  is  employed  from  its  continued 
use  by  the  author  in  class  work  rather  than  the  deductive — com- 
monly known  as  ease  teaching — because  the  former  allows  a  more  com- 
plete picture  of  a  disease  to  be  presented,  though  it  must  be  confessed 
it  is  often  artificial,  and  the  latter  much  better  "holds  the  mirror  up, 
to  nature." 

The  names  of  authorities  are  scantily  mentioned  in  this  treatise, 
since  no  hope  of  making  an  encyclopedia  of  it  has  ever  occurred  to 
the  author — not  because  he  feels  under  any  the  less  obligations  to 
those  authorities  for  a  mine  of  information,  which  no  one  man  could 
have  acquired  alone  in  a  lifetime.     The  works  of  Boas,  E.  Schuetz, 


PREFACE 

A.  and  R.  Schmidt,  Lefmanu,  Riegel,  Zweig,  Wegele,  and  Hemme- 
ter,  as  well  as  the  well-filled  volumes  of  the  Archiv  fiir  Verdauungs- 
krankheiten,  have  been  freely  consulted  for  observations  on  the  rarer 
diseases  which  have  never  come  under  the  eye  of  the  author,  and  for 
which  they  often,  in  turn,  give  thanks  to  the  original  observer.  The 
wisdom  of  combining  a  consideration  of  the  diseases  of  the  stomach 
with  those  of  the  intestines  seems  fully  justified  by  the  intimate  as- 
sociation of  the  two,  as  well  as  from  the  reflex  action  which  one 
group  exerts  on  the  other;  we  need  only  mention  the  gastroduodenal 
ulcer  and  the  effect  of  the  chronically  inflamed  appendix  on  the  gas- 
tric functions.  An  attempt  has  also  been  made  to  show  the  correla- 
tion of  these  diseases  with  those  of  other  organs — as,  for  instance, 
pulmonary  tuberculosis,  pernicious  anemia,  and  nephritis — lest  we  be 
carried  away  with  the  idea  that  disturbances  of  the  digestive  func- 
tions are  always  primary  ones  and  we  recognize  no  organs  in  the 
body  but  the  digestive  tract.  An  effort  has  also  been  made  to  show 
that  every  successful  diagnosis  rests  like  a  stool  upon  four  legs — 
history,  physical  examination,  chemical  analysis,  and  radiology — 
without  expressing  any  great  confidence  in  either  oile  when  taken 
alone.  The  methods  of  investigation  employed  are  those  in  daily 
use  in  the  author's  clinics;  there  are  many  others — undoubtedly 
equally  ^  good,  and  perhaps  even  better — ^but  from  the  multitude 
these  have  been  chosen  for  their  practical  application  and  ease  of 
accomplishment  in  a  clinic,  where,  of  necessity,  methods  must  differ 
from  those  of  a  research  laboratory.  The  pathology  of  these  dis- 
eases has  been  lightly  touched,  and  then  only  when  there  seemed  a 
close  connection  between  the  symptoms  and  the  underlying  pathologic 
condition  producing  them,  like  that  of  gastric  ulcer  and  mesenteric 
embolism,  for  the  purpose  was  to  make  this  a  clinical  work.  Having 
during  a  somewhat  busy  life  passed  through  many  periods  of  mild 
intoxication  on  the  part  of  the  medical  profession  from  new  discov- 
eries, supposed  to  outlast  time,  but  now  forgotten,  many  of  the  newer 
investigations,  not  fully  established,  remain  unmentioned;  time  will 
ripen  them  if  worthy  of  credence,  and,  if  doomed  to  be  disappoint- 
ments, we  need  not  spoil  our  taste  for  the  perfect  fruit.  Among  these 
is  that  of  ileal  stasis,  which  seems  altogether  too  common  to  indicate 
a  true  pathologic  condition. 

Treatment  is  considered  in  all  its  bearings — dietetic,  physical, 
medicinal,  and,  we  may  well  add,  psychic,  though  as  yet  we  are 
obliged  to  coat  the  pill  with  the  phrase  of  "change  of  scene  and  cli- 
mate."    In  medicinal  treatment  many  of  our  old  remedies  are  re- 


PREFACE 

tained,  while  only  the  new  agencies  are  mentioned  which  have  been 
used  by  the  author  and  found  worthy  of  confidence.  On  the  basis 
that  ''figures  never  lie,  but  statistics  may,"  but  little  space,  outside 
of  the  outcome  of  surgical  operations,  is  given  to  the  numerical 
frequency  of  disease;  they  more  often  enable  a  writer  to  enumerate 
some  very  satisfactory  totals  in  his  own  practice,  but  rarely  have 
much  value  for  drawing  deductions  unless  added  to  those  of  him- 
dreds  of  others,  so  that  the  final  summary  shall  be  something  stu- 
pendous. 

The  thanks  of  the  author  are  due  to  Dr.  A.  W.  George  for  his 
very  excellent  radiographs  which  he  has  allowed  him  to  present  in 
this  volume. 

A.  Everett  Austin. 


CONTENTS 

PART  I.     GENERAL  CHARACTERISTICS. 

CHAPTER  I. 

PAGE 

Surface  Anatomy  of  the  Stomach  and  Intestines    17 

The  Stomach   17 

The   Intestines    22 

Blood  and  Xerve  Supply  of  the  Abdominal  Organs   26 

CHAPTER  II. 

The  Physiology  of  Digestion 29 

Oral   Digestion    29 

Digestion   in   the   Stomach    31 

Intestinal   Digestion    37 

CHAPTER  III. 

'  Examination    of    the    Patient    46 

The    History     48 

Subjective  Symptoms    55 

CHAPTER  IV. 

Physical  Methods  of  Examination  of  the  Digestive  Tkact 72 

Inspection     72 

Palpation    80 

Percussion  of  the  Gastrointestinal  Tract 93 

Auscultation   of  the  Gastrointestinal  Tract    100 

Succussion    Sounds 103 

Radiological  Examination  of  the  Tract 106 

Results    of    the    X-ray    Examinations 121 

Rectoscopic    Examination      127 

CHAPTER  V. 

Acquisition   and   Examination   of   Gastric   Contents 130 

Contraindications    135 

Examination  of  Gastric  Contents 136 

Test  Meals 136 

Macroscopic   Examination    139 

Chemical   Examination   of  Gastric   Contents 145 

Microscopic  Examination 160 

Microorganisms     162 


CONTENTS 

CHAPTER  VI. 

PAGE 

Examination   of   Feces    166 

General    Characteristics     ,   169 

Consistency  of  Stools   169 

Color  of  Feces    170 

Odor    of    Feces     171 

Food    Fragments 172 

Xormal   Stool 172 

Pathologic   Stool    172 

Pathologic  Products  of  the  Intestinal  Mucous  Membrane 180 

CHAPTER  VII. 

Dietetics  in  Digestive  Disorders    195 

-      Prophylaxis    196 

Character  of  Foods   199 

Liquid    Xourishment     200 

Solid  Food  208 

CHAPTER  VIII. 

Treatment  of  Digestive  Disorders  224 

Dietetic   Treatment    224 

Physical   Treatment   of   Digestive   Disorders    2.30 

Treatment  of  Intestinal  Diseases   257 

Continuous    Irrigation     259 

Nutrient  Enemata    259 

Medicinal    Treatment    262 

Surgical  Treatment  of  the  Gastrointestinal  Ciinal    274 

PART  II.     SPECIAL  GASTRIC  DISEASES. 

CHAPTER  IX. 

Acute    and    Chronic    Gastritis     295 

Acute  Gastritis   295 

Chronic    Gastritis    298 

CHAPTER  X. 
Gastric  Ulcer     305 

CHAPTER  XI. 
Ectasia   Ventriculi    (  Dilatation    of   the    Stomach  )     324 

CHAPTER  XII. 
Cancer  of  the   Stomach    335 

CHAPTER  XIII. 

Enteroptosis    (  Splanchnoptosis  )     347 

Gastroptosis     351 

Coloptosis     354 

Xephroptosis    356 

Treatment     359 


CONTENTS 

CHAPTER  XIV. 

PAGE 

Nekvotjs  Dyspepsia   (Gastric  Neurosis)    365 

Secretory   Neuroses 366 

Achylia  Gastrica    372 

Disturbances  of  Motility    376 

Sensory  Disturbances    389 

PART  III.     SPECIAL  INTESTINAL  DISEASES. 
CHAPTER  XV. 

FuN^CTioNAL  Disturbances  of  Intestinal  Digestion   (Intestinal  Indiges- 
tion)   397 

Acute  Intestinal  Indigestion   397 

Chronic  Gastrogenous  Intestinal  Indigestion    399 

Intestinal    Fermentative    Indigestion    402 

Habitual    Functional    Constipation     406 

Parasitic  Intestinal  Indigestion   422 

Intestinal  Indigestion  in  Basedow's  Disease    426 

Intestinal  Indigestion  from  Degeneration   427 

Nervous   Diarrliea    428 

CHAPTER  XVI. 

Inflammatory  Diseases  of  the  Intestine    430 

Gastroenteritis    431 

Enterocolitis    434 

Enteritis     441 

Typhlitis     442 

Appendicitis       448 

Chronic   Appendicitis    452 

Colitis     457 

Chronic  Mucous  and  Membranous  Colitis 461 

Ulcerative   Colitis    467 

Sigmoiditis   and   Perisigmoiditis      471 

Proctitis  and  Periproctitis 475 

CHAPTER  XVII. 

Ulcerative  Processes  of  the  Intestine  and  their  Sequels  480 

Duodenal   Ulcer    481 

Intestinal    Tuberculosis 485 

CHAPTER  XVIII. 

Diseases  of  the  Intestinal  and  Mesenteric  Blood  Vessels   490 

Venous    Hyperemia     490 

Hemorrhoids    491 

Arteriosclerosis     490 

Embolism  and  Thrombosis    499 


CONTENTS 

CHAPTER  XIX. 

PAGE 

Intestinal  Stenoses  and  Occlusions    502 

Stenoses    502 

Occlusion    507 

Strangulation    508 

Invagination    508 

CHAPTER  XX. 

Malignant  Growths  of  the  Intestine    515 

Rectal    Cancer 517 

Colon  Cancer   518 

Cancer  of  the  Duodenum   523 

Cancer   of   the    Small    Intestine 524 

Polypi 527 

CHAPTER  XXI. 

Nebvous  Diseases  of  the  Intestine 529 

Cramp   or   Spasm   of  the   Intestine    530 

Peristaltic  Unrest    532 

Paresis  or  Paralysis  of  the  Intestine   533 

Loss  of  Action  of  the  Sphincter 536 

Disturbances    of    Secretion    537 

Disturbances  of  Sensation   537 

Intestinal   Hyperesthesia    538 

Intestinal  Neuralgia    530 


ILLUSTRATIONS 

FIG.  PAGE 

1.  Position   of  normal   stomach  determined  by   palpation,   percussion   and 

x-ray         19 

2.  Normal  stomach,  "horn  form" 20 

3.  Normal  stomach,  "crook  form" 21 

4.  Topographical   anatomy   of   the   duodenum 23 

5.  Position  of  the  normal   colon 24 

6.  Kadiogram  of  congenitally  displaced  colon 25 

7.  Gastrointestinal  nerve  supply 27 

8.  Normal  movements  of  the  contents  of  the  colon 39 

9.  Stenosis  in  the  vicinity  of  the  splenic  flexure 76 

10.  Stenosis  of  the  lower  ileum  from  peritoneal  adhesion 77 

11.  Normal    intestinal    peristalsis 79 

12.  Epigastric    pressure    point 82 

13.  Dorsal   pressure   point   in  gastric  ulcer 84 

14.  Dorsal   pressure   point   in   cholelithiasis 85 

15.  Normal   form  of  the  stomach 96 

16.  Stomach    with    malignant   disease   of   the    cardia 102 

17.  Gastric  cancer 112 

18.  Normal  bulbous  duodenum    (bishop's  cap) 115 

19.  Carcinoma  of  the  cecum  with  stenosis 118 

20.  Cancer  of  the  rectum,  bismuth  ingested 119 

21.  Adhesions  of  parts  of  the  colon 120 

22.  Von  Aldor's  rectoromanoscope 128 

23.  Gastric  tube 131 

24.  Sectional  view  of  tube  in  place  between  larynx  and  post-pharyngeal  wall  132 

25.  Food  particles 160 

26.  Pathologic    indications 161 

27.  Microorganisms .  163 

28.  Microscopic   appearance  of   normal   stool   on   test  diet.      (Color   Plate)  168 

29.  Gross  appearance  of  stool  containing  excess  of  connective  tissue.      (Color 

Plate) 168 

30.  Microscopic  appearance  of  meat  fibers  in  stool  well  stained  with  hvdro- 

bilirubin.      (Color   Plate)         \      .  170 

31.  Microscopic  appearance  of  meat  fibers   in  stool  stained  with  nile  blue 

sulphate.     (Color  Plate) 170 

32.  Fat  clumps  in  mixed  feces  from  test  diet.      (Color  Plate) 172 

33.  Gross   appearance  of   fattv   stools  with   disturbed   absorption.     (Color 

Plates) " 172 

34.  Microscopic  appearance  of  fat  in  stools  stained  with  nile  blue  sulphate. 

(Color    Plate) 174 

35.  Microscopic  appearance  of  partially  digested  fat,  stained  with  nile  blue 

sulphate.      (Color  Plate) 174 

36.  Microscopic  appearance  of  unstained  fatty  stools,  fatty  acids  in  excess  175 

37.  Fermentative^  stools  containing  potato  cells  and  Clostridia,  stained  with 

Lugol's  solution.      (Color  Plate) 176 

38.  Microscopic  appearance  of  mucus  from  small  intestine 181 

39.  ^Microscopic  appearance  of  colon  mucus  with  "shriveled"  cells    .      .      .182 

40.  Microscopic  appearance  of  pus  flakes  from  feces  in  chronic  diarrhea  .      .  183 

41.  Microscopic    appearance    of    various    abnormal    fecal    bacteria.      (Color 

Plate)         186 

42.  Tenia  saginata,  showing  egg  of  same  enlarged  four  hundred  times   .      .  187 


ILLUSTRATIONS 
FIG.  PAGE 

43.  Segment  of  Tenia  saginata,  enlarged  twelve  times 188 

44.  Tenia  solium,  showing  egg  of  same  enlarged  four  hundred  times  .      .      .189 

45.  Segment  of  Tenia  solium,  enlarged  twelve  times 190 

46.  Pinworm   (Oxyuris  vermicularis) ,  natural  size 192 

47.  Egg  of  pinworm,  enlarged  twelve  hundred  times 192 

48.  Hookworm  (Ankylostoma  duodenale),  natural  size 193 

49.  Egg  of  hookworm,  showing  segmentation,  enlarged  twelve  hundred  times  193 

50.  Abdominal  massage,  first   manipulation  * 241 

51.  Abdominal  massage,  second    manipulation 241 

52.  Abdominal  massage,  third  manipulation 242 

53.  Abdominal  massage,  fourth    manipulation 242 

54.  Abdominal  massage,  fifth   manipulation 243 

55.  Abdominal  massage,  sixth  manipulation .  243 

56.  Abdominal  massage,  seventh    manipulation 244 

57.  Abdominal  massage,  eighth  manipulation 244 

58.  Abdominal  massage,  ninth  manipulation 245 

59.  Portable  electric  vibrator 246 

60.  Crank  vibrator,  with  pulsating  cushion 247 

61.  Intragastric  electrode 248 

62.  Wegele's  intragastric  electrode 249 

63.  Zweig's  rectal  electrode 250 

64.  Gastric  lavage,  introduction  of  the  tube  with  head  bowed 251 

65.  Gastric  lavage,  filling  the  funnel 252 

66.  Gastric  lavage,  filling  the  stomach  by  gravity 253 

67.  Gastric  lavage,  emptj'ing  the  stomach  by  siphonage 254 

68.  Double   current  rectal   tube 258 

69.  Radiogram  of  stomach  in  congenital  gastroptosis 352 

70.  Radiogram  of  W-shaped  colon 354 

71.  Storm  binder  for  gastroptosis 360 

72.  Application  of  plaster  according  to  the  Rose  method,  rear  view  .      .      .  361 

73.  Application  of  plaster  according  to  the  Rose  method,  front  view  .      .      .  361 

74.  Enriquez  air  cushion,  with  bulb  for  inflation 362 

75.  Radiogram  of  stomach  before  use  of  Enriquez  air  cushion 363 

76.  Radiogram  of  stomach  after  six  months'  use  of  Enriquez  air  cushion   .  363 

77.  Radiogram  of  colon  before  use  of  Enriquez  air  cushion 363 

78.  Radiogram  of  colon  after  use  of  Enriquez  air  cushion 363 

79.  Radiogram  of  marked  looping  of  colon,  accompanied  by  constipation  .      .411 

80.  Radiogram  of  rectum  packed  with  feces 412 

81.  Radiogram  of  cecum  mobile  (bismuth  ingested) 444 

82.  Radiogram  of  duodenal   ulcer 483 

83.  Rectal  pessary 495 

84.  Radiogram  of  cancer  of  the  descending  colon  (bismuth  ingested)    .      .      .  521 

85.  Radiogram  of  cancer  of  the  hepatic  flexure  of  the  colon    (bismuth  in- 

gested)   522 


PART  I 
GENERAL  CHARACTERISTICS 


DISEASES  OF  THE  DIGESTIVE  TRACT 

CHAPTER  I 
SUKFACE  ANATOMY  OF  THE  STOMACH  AND  INTESTINES 

When  we,  as  clinicians,  look  upon  an  abdomen,  the  true  anatomical 
position  of  the  organs  as  they  appear  to  the  anatomist  and  the  sur- 
geon does  not  interest  us  as  much  as  their  relative  positions  upon 
the  abdominal  surface  as  determined  by  the  physical  means  of  ex- 
amination, palpation,  and  percussion.  Hence  it  is  the  surface  anatomy 
which  we  must  ever  bear  in  mind.  Based  on  such  groundwork,  we 
find  that  the  lesser  curvature  escapes  our  detection  in  the  normally 
situated  stomach,  and  we  are  forced  to  content  ourselves  with  the 
delineation  of  the  greater  curvature,  the  fundus,  and  possibly  the 
pylorus,  while  the  other  portions  remain  obscured  by  their  situation 
under  the  liver  and  the  heart. 

THE  STOMACH. 

This  organ  extends  from  the  liver  and  the  left  vault  of  the  dia- 
phragm on  its  upper  surface  to  the  duodenum  and  transverse  colon, 
which  form  a  kind  of  cushion  for  it,  and  in  front  rests  on  the  ab- 
dominal wall.  On  the  left  it  rests  against  the  spleen,  comprising  that 
portion  completely  under  the  ribs,  which  is  known  as  Traube's  semi- 
lunar space.  On  the  right  it  touches  the  median  border  of  the  gall 
bladder,  which  accounts  for  the  frequency  with  which  the  pylorus  is 
found  adherent  to  this  viscus  in  cholelithiasis  and  cholecystitis. 
Three-fourths  of  the  stomach  is  found  to  the  left  of  the  median  line, 
while  that  portion  which  is  found  to  the  right  comprises  the  pylorus 
and  a  part  of  the  fundus,  while  the  former  is  rarely  palpable  be- 
cause covered  by  the  liver.  The  pyloric  portion  usually  makes  a 
sharp  bend  at  the  median  line  and  extends  to  the  right,  upward  and 
backward,  until  it  reaches  the  right  costal  arch.  The  pylorus  lies 
usually  at  the  level  of  the  seventh  or  eighth  rib,  and  a  line  drawn 

17 


18  DISEASES   OF   THE   DIGESTIVE   TRACT 

midway  between  the  left  sternal  and  parasternal  lines  vertically  and 
one  drawn  horizontally,  midway  between  the  suprasternal  notch  and 
the  public  symphysis,  cross  directly  over  the  pylorus.  This  always 
gives  an  approximate  idea  where  one  should  look  for  the  point  of 
tenderness,  usually  well  defined  in  gastric  ulcer  if  confined  to  the 
pylorus. 

The  cardia  can  usually  be  found  at  the  height  of  the  sixth  or  seventh 
rib  at  the  left  sternal  border;  as  this  portion  of  the  stomach  is  com- 
pletely covered  by  the  left  lobe  of  the  liver,  growths  at  this  point 
can  not  be  felt  unless  there  is  marked  ptosis  of  the  organ.  For  prac- 
tical purposes  it  is  very  desirable  to  know  the  upper  and  lower  bor- 
ders of  the  stomach,  which  can  be  determined  by  intermediate  or 
direct  percussion  when  the  organ  is  moderately  distended  with  gas 
or  on  ingestion  of  the  tartaric  acid-sodium  bicarbonate  mixture;  in 
the  normal  the  highest  portion,  the  fundus,  can  be  found  in  the  mid- 
axillary  line  at  the  level  of  the  fifth  rib,  while  the  lowest  part  will 
be  found  to  correspond  with  a  horizontal  line  drawn  3  to  4  cm.  above 
the  navel. 

Attachments  of  the  Stomach. — The  upper  portion  of  the  fundus 
is  closely  attached  to  the  diaphragm  and  follows  its  movements,  so 
that  the  cardia  is  individually  immovable ;  this  immovability  is  still 
further  enforced  by  the  gastro-hepatie  ligament,  which  extends  from 
the  cardia  to  the  right.  The  pyloric  end,  on  account  of  close  associa- 
tion with  the  duodenum,  which  is  loosely  attached  to  the  side  of  the 
spinal  column  without  any  firm  bands,  possesses  a  fairly  large  de- 
gree of  movability,  particularly  downward,  so  that  prolapses  of  this 
part  of  the  stomach,  both  congenital  and  acquired,  are  not  uncommon, 
and  in  the  cadaver  it  can  often  be  found  to  have  descended  almost 
into  the  pelvis.  From  the  greater  curvature  the  omentum  drops 
like  an  apron  over  the  coils  of  small  intestine,  turns  about,  and  ascends 
to  the  colon,  to  which  it  is  attached ;  that  portion  between  the  stomach 
and  transverse  colon  is  called  the  gastro-colic  ligament,  and  is  some- 
times beset  with  cancerous  nodules  when  malignant  disease  of  the 
stomach  exists.  By  overdistention  of  the  stomach  the  lower  portion 
of  the  stomach  can  extend  downward  until  it  reaches  the  pelvis,  or 
even  the  pubis,  in  spite  of  its  attachments.  The  actual  position  of 
the  stomach  with  reference  to  navel,  ribs,  and  liver  has  been  carefully 
ascertained  by  Lichtenbelt  by  percussion,  palpation  with  introduced 
stomach  tube,  and  x-ray,  as  shown  in  a  composite  picture  (Fig.  1). 

Position  and  Form  of  the  Stomach  as  Determined  by  X-Ray. — 
Our  views  of  the  shape  of  the  stomach  have  been  very  decidedly 


SURFACE   ANATOMY   OF   THE   STOMACH   AND   INTESTINES 


19 


changed  by  examination  of  the  radiograms  obtained  after  the  bismuth 
meal.  The  normal  stomach  under  these  conditions  assumes  more  of 
a  tube  shape,  lying  chiefly  to  the  left  of  the  median  line;  on  stand- 
ing, the  long  axis  takes  a  perpendicular  direction  and  in  the  lying 
position  more  of  a  diagonal.  In  the  prone  position  the  fundus  takes 
a  higher  level,  while  the  pylorus  remains  stationary  and  the  air 


Fig.  1. — Position  of  the  normal  stomach  determined  by  palpation,  percussion  and  x-ray. 


bubble  disappears.  The  stomach  has  turned  on  its  axis,  which  we 
must  consider  as  extending  from  the  cardia  to  the  pylorus.  The 
change  which  takes  place  in  the  stomach  on  change  of  position  of 
the  body  must  be  due  in  a  large  degree  to  the  weight  of  the  bismuth 
which  drags  down  the  lower  pole  of  the  stomach  on  standing,  but 
fails  of  this  eifect  when  the  patient  is  prone.     The  greater  and  lesser 


20 


DISEASES   OF   THE  DIGESTIVE   TRACT 


curvatures  run  nearly  parallel  downward  to,  perhaps,  four-fifths  of 
its  length,  when  a  sharp  turn  takes  place  and  the  remainder  of  the 
stomach  takes  an  upward  direction,  reaching  a  greater  or  less  ele- 
vation, according  to  the  position  of  the  pylorus,  which,  of  course, 
it  reaches.  The  pylorus,  as  well  as  the  lesser  curvature,  are  covered 
by  the  normal  liver.     Under  abnormal  conditions,  however,  the  pylorus 


Fig.  2. — Normal  stomach,   "horn  form."      (Prom  collection  of  Dr.  Arial  W.  George.) 

may  be  found  under  the  liver.  It  is  only  just  to  say  that  Stiller  re- 
gards this  tubelike  form  of  the  stomach  as  a  distorted  or  artificial 
form  produced  by  the  unnatural  stimulation  of  the  large  amount  of 
bismuth  which  forces  the  stomach  to  a  more  than  physiological  con- 
traction, while  Hesse,  who  used  bone  shavings  instead  of  bismuth, 
claims  that  the  form  of  the  stomach  remains  the  same  as  when  bis- 


SURFACE   ANATOMY   OF    THE   STOMACH    AND    INTESTINES 


21 


muth  is  used.  It  is  also  true  that  the  rontgen  pictures  of  the 
stomach  vary  very  decidedly  according  to  age,  shape  of  the  body 
(narrow  chest),  and  other  peculiarities.     In  spite  of  this,  however, 


Fig.  3. — Normal  stomach,  "crook  form."      (From  collection  of  Dr.  Arial  W.  George.) 

two  general  forms  can  be  usually  distinguished — ^the  so-called  "horn 
form"  and  the  shepherd's  "crook  form,"  of  which  the  latter  is  the 
more  common.     (Fig.  2,  3.) 


22  DISEASES   OF   THE   DIGESTIVE   TRACT 

\ 

THE  INTESTINES. 

The  first  portion  of  the  intestine,  the  duodenum,  25  em.  in  length, 
takes  a  U-shaped  course  from  the  pylorus  to  the  jejunum,  lying  wholly 
to  the  right  of  the  median  Rne,  and  can  be  found  in  the  epigastric 
and  upper  umbilical  portion  of  the  abdomen,  a  thing  which  should 
be  borne  in  mind  when  seeking  the  point  of  tenderness  in  duodenal 
ulcer.  The  first,  or  upper,  part  is  just  behind  the  costal  cartilage  of 
the  eighth  right  rib  to  the  left  of  the  gall  bladder ;  the  second  portion 
passes  directly  downward  from  the  gall  bladder  in  the  right  midclavi- 
cular or  parasternal  line  in  front  of  the  kidney  to  the  level  of  the 
navel  or  just  short  of  it ;  the  third  part  runs  obliquely  upward  to  the 
transpyloric  line  2.5  cm.  from  the  median  line,  where  it  forms,  with 
the  jejunum,  the  duodeno-jejunal  flexure.  It  should  be  remembered 
that  the  head  of  the  pancreas  projects  into  the  curve  of  the  duodenum ; 
that  behind  the  duodenum  lie  the  common  bile  duct,  the  right  kidney, 
the  portal  vein,  and  the  inferior  vena  cava,  while  in  front  of  it  are 
the  liver,  gall  bladder,  and  transverse  colon.  It  is  anchored  to  the 
posterior  abdominal  wall,  and  hence  is  not  movable.  These  relations 
are  very  well  shown  in  Fig.  4. 

The  jejunum  fills  the  upper  umbilical  region  and  parts  adjoining  to 
the  left,  while  the  ileum  is  below  it  and  to  the  right.  The  coils  of  the 
small  intestine  often  lie  before  the  ascending  and  descending  colon. 
At  times,  when  distended,  they  may  fill  the  right  hypochondrium,  en- 
croaching on  the  region  of  liver  dullness,  according  to  ]\Iayer.  The 
colon,  beginning  with  the  cecum,  which  lies  in  the  right  iliac  fossa  2.5 
cm.  below  a  line  extending  from  the  navel  to  the  anterior  superior 
iliac  spine,  extends  upward,  forming  the  ascending  portion  to  the 
right  costal  border,  where  it  makes  a  sharp  bend  to  the  left,  the 
hepatic  flexure.  Before  leaving  this  portion  of  the  colon  we  must 
call  attention  to  the  appendix,  which  leaves  the  cecum  2.5  cm.  below 
the  ileocecal  valve — i.  e.,  5  cm.  below  the  middle  of  the  line  from  the 
navel  to  the  anterior  superior  spinous  process.  From  this  point  it 
extends  to  the  left  in  more  or  less  of  a  drooping  curve,  with  the 
concavity  upward,  but  normally  above  the  navel  to  the  left  costal 
arch,  under  which  it  disappears  and  here  forms  a  curve  upward, 
backward,  and  to  the  left  to  form  the  splenic  flexure  below  the  spleen 
and  back  of  the  stomach ;  the  splenic  flexure  is  found  at  a  higher  level 
than  the  hepatic.  From  this  point  it  extends  vertically  downward 
to  the  iliac  crest,  forming  the  descending  portion,  where,  as  the  sig- 


SURFACE   ANATOMY   OP    THE   STOMACH   AND   INTESTINES 


23 


moid  flexure,  following  a  more  or  less  crooked  course,  it  makes  its  way 
to  the  rectum,  which  it  reaches  opposite  the  third  segment  of  the 
sacrum.  In  connection  with  the  site  of  the  union  of  the  sigmoid 
and  the  rectum,  it  is  well  to  remember  that  a  soft  tube  can  rarely 
be  passed  more  than  15  cm.  into  the  rectum  before  it  meets  with  re- 
sistance, and,  if  pushed  still  farther,  it  turns  on  itself  and  no  fluid 


Gall  bladder  J 


Hepatic  duet 
Cystic  duct 


Cystic  artery 


Superior   port, 
duodenum 


Common  duct 


-  Aorta 

^  Inferior  vena  cava 

■~  Celiac  artery 
Portal  vein 


Descending    port 
duodenum 


—  Superior  mesenteric 
artery 


Fig.  4. — Topographical  anatomy  of  the  duodemim. 

will  run  through  it.  The  rectoscope,  however,  can  easily  be  intro- 
duced to  a  depth  of  25  cm.,  but  opposite  the  promontory  of  the  sacrum 
the  sigmoid  begins.  The  relations  of  the  entire  colon  with  reference 
to  the  surface  of  the  abdomen  are  shown  in  Fig.  5. 

This  position  of  the  colon,  however,  is  very  often  departed  from; 
the  ascending  colon  may  be  shortened  congenitally  or  fail,  so  that 
the  cecum  and  the  appendix  may  lie  at  the  edge  or  even  under  the 


24 


DISEASES  OP   THE   DIGESTIVE   TRACT 


right  lobe  of  the  liver,  thus  sadly  confusing  the  pain  of  an  appendicitis 
with  that  of  a  gall  bladder  affection.  Again,  the  shortening  may 
act  in  bringing  the  hepatic  flexure  far  below  the  right  costal  border,  so 
that  the  direction  of  the  colon  from  the  cecum  is  almost  a  diagonal 


Fig 


-Position  of  the  normal  colon. 


across  the  abdomen,  ascending  to  the  splenic  flexure ;  this  is  a  common 
form  in  x-ray  pictures,  and  whether  exaggerated  by  the  bismuth  can 
not  be  stated  with  certainty.  Then,  the  transverse  colon  may  be  so 
long  that  a  long  loop  may  extend  almost  to  the  pubis,  or  a  double  loop 


SURFACE   ANATOMY   OF    THE   STOMACH    AND    INTESTINES 


25 


or  inverted  !M-shape  may  be  found.  This  redundancy  of  colon  may 
be  pulled  upward,  so  that  it  may  lie  before  the  liver  in  the  epigastrium 
or  before  the  stomach  in  the  left  hypochondrium.  The  flexures,  too, 
may  be  incomplete,  and  then  the  two  lateral  and  vertical  portions 


Fig.  6. — Radiogram  of  congenitally  displaced  colon. 

George.) 


(From  collection  of  Dr.  Arial  VV. 


of  the  colon  converge  upward  and  often  form  a  great  loop,  which 
covers  the  whole  anterior  surface  of  the  liver.  These  vagaries  of  the 
colon  are  so  often  shown  by  radiograms  that  they  can  hardly  be  re- 
garded as  abnormalities  and  often  cause  no  symptoms,  though  they 


26  DISEASES  OP  THE  DIGESTIVE  TRACT 

may  be  associated  with  functional  constipation.     Fig,  6  shows  one 
of  these  many  distortions. 

Moreover,  the  sigmoid,  when  there  is  a  redundant  colon,  may  as- 
sume the  most  fantastic  directions,  exaggerations  of  the  erratic  course 
of  the  normal  sigmoid,  and  be  found  in  the  middle  of  the  abdomen, 
covered  by  small  intestine,  or  extending  to  the  xiphoid  or  even 
lying  over  the  liver.  Then,  again,  there  may  be  a  fold  between  the 
lower  end  of  the  sigmoid  and  the  beginning  of  the  rectum,  which 
passes  to  the  right  and  descends  along  the  cecum  to  the  pelvis  minor. 

BLOOD  AND  NERVE  SUPPLY  OF  THE  ABDOMINAL  ORGANS. 

The  abdominal  aorta  runs  to  the  left  of  the  linea  alba  from  the 
ensiform  to  the  level  of  the  highest  part  of  the  iliac  crest.  At  this 
point  the  aorta  divides  into  the  two  common  iliac  arteries,  which  then 
run  toward  a  point  midway  between  the  anterior  iliac  spine  and  the 
pubis.  The  pulsations  of  the  aorta  are  particularly  noticeable  when 
the  stomach  has  undergone  a  state  of  ptosis,  particularly  if  it  is 
empty,  and  often  cause  marked  annoyance  to  the  patient.  The  right 
common  iliac  can  also  be  seen  pulsating  when  the  cecum  is  filled 
with  feces,  but  I  have  never  noticed  the  left.  The  aorta  can  also  be 
felt  in  women  with  lax  abdomens  under  the  same  conditions — i.e., 
where  gastroptosis  exists.  The  arteries  which  ascend  to  the  epithelial 
cells  of  the  stomach  are  end  arteries,  so  that  their  closure  by  any 
cause  leaves  that  part  of  the  mucous  membrane  without  nutrition  and 
subject  to  digestion  by  the  gastric  juice,  a  supposedly  common  cause 
of  gastric  ulcers.  One  branch  of  the  hepatic  artery,  the  gastro- 
duodenalis,  is  of  some  importance,  since  it  runs  along  the  border  be- 
tween the  pylorus  and  the  duodenum  and  is  made  much  of  by  sur- 
geons as  marking  the  pyloric  ring  and  differentiating  the  gastric 
from  the  duodenal  ulcer.  The  superior  mesenteric  artery,  after  sup- 
plying the  lower  duodenum  and  the  head  of  the  pancreas,  sends  off 
sixteen  to  eighteen  branches,  the  arteriae  jejunales  et  ileae,  which  supply 
the  corresponding  parts  of  these  two  divisions  of  the  small  intestine; 
each  one  divides  into  two  branches,  which  anastomose  in  the  shape  of 
an  arch  with  those  lying  next.  From  these  arches  there  spring  smaller 
branches,  which  act  in  the  same  way  until  three  or  four  rows  of  these 
arches  follow ;  the  importance  of  this  is  that,  if  an  embolus  plugs  one 
of  the  larger  branches,  a  large  section  of  the  intestine  is  deprived  of 
nutriment  and  complete  obstruction  may  follow,  a  condition  seen  once 
by  myself  and  discovered  only  at  autopsy.     The  veins  of  the  stomach 


SURFACE   ANATOMY   OF    THE    STOMACH   AND   INTESTINES  27 

empty  into  the  portal  vein  for  the  greatest  part,  so  that  in  cirrhosis  of 
the  liver,  and  other  conditions  where  the  portal  circulation  is  impeded, 
hemorrhage  of  the  stomach  is  not  uncommon.  Nor  should  we  lose 
sight  of  the  fact  that  the  veins  of  the  lower  intestinal  tract  also  empty 
into  the  portal  vein,  and  thereby  sometimes  bring  infectious  matter 
from   the   sections   involved — purulent    appendix,   dysentery,    etc. — 


Fig.  7.-Gastrointestinal  nerve  supply    \  ^^^l^^^Tetentevic  plexus. 

which  may  cause  a  purulent  phlebitis  of  the  portal  and  consequent 
thrombosis.  The  position  of  the  celiac  plexus,  on  a  horizontal  line 
joining  the  cartilages  of  the  ninth  ribs  and  a  little  to  the  right  of  the 
median  line,  has  a  marked  significance  because  here  is  often  found 
the  epigastric  tender  spot,  whether  due  to  an  ulcer  or  to  so-called 
nervous   dyspepsia.     The   site   of  the  plexus   mesentericus  superior, 


28  DISEASES   OF   THE   DIGESTIVE   TRACT 

at  or  near  the  point  of  bifurcation  of  the  aorta,  must  also  be  borne 
in  mind,  since  it  represents  often  a  point  of  tenderness  to  pressure, 
which  may  mean  either  the  supersensitiveness  due  to  a  nervous  dis- 
order, or  a  hyperesthesia  due,  by  means  of  reflex  action,  to  some 
organic  disease  of  the  abdomen.  There  is  also  in  the  left  iliac  region 
a  plexus,  the  mesentericus,  which  has  the  same  relative  position  on 
the  left  as  McBurney's  point  has  on  the  right,  and  which  marks  a 
common  point  of  tenderness.  The  McBurney's  point  itself  is  no 
other  than  a  plexus,  the  ileocolic,  lying  in  the  angle  between  the 
ileum  and  the  colon,  and  tenderness  over  this  plexus  does  not  in- 
variably mean  inflammation  of  the  appendix,  as  has  been  so  gen- 
erally supposed.  It  is  of  the  greatest  diagnostic  importance  to 
remember  that,  by  means  of  radiation,  pain  or  tenderness  at  one  plexus 
may  be  felt  at  another;  for  instance,  in  a  true  appendicitis,  pain 
may  be  felt  at  the  navel  (mesentericus  superior)  or  at  the  epigastrium 
(celiac),  and  that,  on  pressure  over  the  ileocolic,  tenderness  Avill  be 
found  at  this  point  as  well  as  at  the  distant  points,  and  sometimes 
more  extensively  at  the  distant  points.  The  reverse  is  also  true,  and 
tenderness  over  the  celiac  due  to  gastric  ulcer  may  be  felt  at  Mc- 
Burney's point;  only  in  this  way  can  we  account  for  the  frequent 
removal  of  the  appendix  without  relief  of  the  pain  and  the  later  dis- 
covery of  a  chronic  gastric  ulcer.  The  natural  reason  for  this  trans- 
ference of  tenderness  from  the  actual  point  of  irritation  to  a  distant 
one  is  the  abundant  anastomoses  existing  between  the  various  plexuses 
of  the  abdomen.  When  we  remember,  too,  that  the  vagus  sends  out 
two  branches,  one  to  the  stomach  and  the  other  through  the  celiac 
plexus  to  the  intestines,  we  can  see  why  an  atonic  stomach  is  so 
often  associated  with  atonic  intestines,  and  why  disturbed  intestinal 
functions  (constipation)  may  by  reflex  action  play  an  important  part 
in  the  secretory  action  of  the  stomach.  This  correlation  of  the  nerve 
supply  of  the  abdominal  digestive  tract  can  be  readily  seen  from  the 
illustration  of  gastrointestinal  innervation,  according  to  ]Mueller 
(Fig.  7). 


CHAPTER  II 
THE  PHYSIOLOGY  OF  DIGESTION 

Digestion  falls  naturally  into  three  divisions — oral,  gastric,  and 
intestinal — and,  in  spite  of  the  fact  that  vicarious  participation 
enables  one  organ  to  do  the  work  of  the  other,  long  experience  soon 
teaches  that  only  perfect  digestion  can  exist  when  each  process  is  com- 
pletely carried  out.  It  may  be  true  as  Cabot  states,  that  he  has  seen 
entire  absence  of  gastric  symptoms  in  an  individual  whose  mouth  is 
free  from  teeth,  or,  as  von  Noorden  claims,  that  metabolism  remains 
the  same  whether  hydrochloric  acid  is  present  in  the  stomach  or  not, 
yet  imperfect  mastication  throws  an  extra  burden  on  the  stomach, 
and  insufficient  gastric  juice  a  similar  one  on  the  duodenum,  and  in 
few  persons  can  this  continue  indefinitely  without  rebellion  on  the 
part  of  the  overburdened  organs,  with  untoward  symptoms.  The 
proof  of  this  fact  also  rests  on  the  results  of  correction  of  these  de- 
ficiencies; senile  dyspepsia,  so-called,  disappears  when  a  well-fitting 
set  of  teeth  is  inserted  and  food  thoroughly  masticated,  and  diarrhea 
ceases  when  the  lacking  hydrochloric  acid  of  the  stomach  is  partially 
replaced  by  its  use  in  medication;  whether  it  acts  in  stimulating 
the  natural  secretion  of  the  stomach,  or  in  causing  a  greater  flow  of 
pancreatic  juice,  is  not  fully  clear,  but  at  least  the  connective  tissue 
and  meat  fibers,  the  former  supposed  to  be  digested  only  by  the  gastric 
juice,  no  longer  form  a  part  of  the  discharges  as  before. 

ORAL  DIGESTION. 

In  the  mouth,  of  course,  if  ordinary  care  be  taken  to  masticate  the 
food,  without  haste  and  without  the  introduction  of  extraneous  fluid 
(tea,  coffee,  water,  etc.),  with  each  mouthful,  the  food  becomes  finely 
divided,  mixed  with  the  saliva  and  rendered  suitable  for  the  future 
action  of  the  gastric  juice.  But  a  still  more  important  act  is  ac- 
complished, for,  if  the  food  possess  a  pleasing  and  acceptable  flavor, 
by  reflex  action  the  gastric  juice  begins  to  flow ;  this  has  been  demon- 
strated so  often  in  humans  with  a  double  esophageal  and  gastric 
fistula,  by  which  all  the  food  taken  passes  out  of  the  former,  that 

29 


30  DISEASES   OF   THE   DIGESTIVE   TRACT 

there  can  be  no  question  of  its  accuracy.  This  shows  the  importance 
o^  the  proper  cooking  and  seasoning  of  food,  as  well  as  the  drawbacks 
to  the  usual  test  breakfast  (bread  and  water),  of  which  patients  com- 
plain as  being  unpalatable  and  allude  to  it  as  state's  prison  fare.  It 
has  been  found  that  by  the  process  of  mastication  not  only  is  the 
food  to  the  extent  of  one-fourth  to  one-third  divided  into  fragments 
less  than  1  mm.  in  diameter,  but  one-third  of  bread  and  potato  is 
rendered  fluid,  in  which,  of  course,  the  saccharification  of  the  saliva 
plays  a  part.  The  food,  thus  prepared  by  chewing,  is  forced  into 
the  stomach  in  individual  portions  by  the  complicated  act  of  the 
muscles  of  the  pharynx  and  esophagus ;  the  reflex,  governing  this  act, 
is  the  contact  of  the  food  with  the  posterior  wall  of  the  pharjTix  and 
roots  of  the  tongue.  The  saliva,  a  tenacious,  alkaline  fluid,  contains, 
as  its  most  active  ingredient,  ptyalin — or  animal  diastase,  as  it  is  some- 
times called — which  does  not  differ,  as  far  as  physiological  action  goes, 
from  the  amylopsin  of  the  pancreatic  juice.  The  saliva  has  a  further 
peculiarity — that,  though  itself  swarming  with  bacteria,  it  allows  few 
to  be  cultivated  from  it,  and  also  has  the  power  of  destroying  certain 
bacterial  poisons.  As  is  well  known,  the  action  of  the  ptyalin  is  to 
convert  the  starch  by  degrees  through  amidulin,  which  gives  a  blue 
color  with  iodine,  to  erythrodextrin,  which  gives  a  violet  to  mahogany 
brown  with  the  same  reagent,  then  to  achroodextrin,  which  gives  no 
color  with  iodine;  then  maltose,  which  gives  prompt  reduction  with 
Fehling's  solution,  is  formed,  and  finally  dextrose,  the  final  product  of 
ptyalin  digestion.  The  act  of  swallowing  consists  of  two  varieties  of 
action;  first,  when  fluids  are  taken,  by  the  muscular  action  of  the 
muscles  of  the  mouth,  especially  of  the  mylohyoid,  the  mouthful  of 
fluid  is  forced  doAvnward  to  just  in  front  of  the  cardia  in  less  than  a 
second 's  time ;  second,  when  solids  are  taken,  each  mouthful  is  driven, 
by  a  progressive  peristalsis  of  the  constrictors  of  the  pharynx  and 
the  muscles  of  the  esophagus,  slowly  downward  to  the  cardia,  requiring 
in  man  from  eight  to  twelve  seconds  for  the  act.  Here  before  the 
cardia  there  is  a  short  delay,  especially  if  fluid  is  taken  in  sips,  and 
solids  are  almost  invariably  delayed  even  to  a  minute's  time  before 
the  cardia  opens.  Fluids  which  are  ice  cold  or  contain  carbonic  acid 
often  cause  a  closure  of  the  cardia,  which  only  slowly  relaxes.  Fur- 
thermore, the  esophagus  enters  the  stomach  at  a  right  angle  to  its 
surface,  forming  a  kind  of  valve,  so  that,  when  the  stomach  is  full  or 
under  tension,  it  prevents  the  return  of  solids,  fluids,  or  gases  from 
the  stomach.  When  liquids  are  forced  to  the  cardia  by  the  com- 
pression of  the  oral  muscles,  there  is  a  subsequent  peristaltic  action  on 


THE  PHYSIOLOGY  OF   DIGESTION  31 

the  part  of  the  esophagus,  which  forces  downward  any  drops  or  small 
fragments  which  may  cling  to  its  walls.  This  double  act  of  swallow- 
ing gives  rise  to  a  double  sound  in  the  normal  individual,  which  is 
best  heard  with  a  stethoscope  over  the  cardia  in  the  xiphoid  region; 
the  first  sound  is  heard  directly  after  the  act  of  swallowing,  but  is  not 
always  constant;  the  second  sound  is  heard  some  seconds  after  the 
beginning  of  the  act  of  swallowing,  which  is  practically  always  heard. 

Different  individuals  react  very  differently  as  to  the  secretion  of 
saliva  when  the  stomach  tube  is  introduced  to  withdraw  the  gastric 
contents;  in  some  there  is  a  flood  of  secretion  from  the  mouth,  con- 
sisting chiefly  of  mucus,  which,  when  the  amount  of  gastric  content  is 
small,  must  play  a  very  important  part  in  reducing  the  acidity  due  to 
free  hydrochloric  acid,  on  account  of  the  avidity  with  which  these 
combine ;  in  others  there  is  little  or  no  secretion  of  saliva.  Chase  has 
devised  a  very  ingenious  funnel  or  ring  which  goes  over  the  tube  and 
prevents  the  saliva  from  entering  the  receptacle  placed  to  receive  the 
gastric  contents. 

It  must  also  be  borne  in  mind  that,  in  the  saliva  and,  from  its 
being  swallowed,  in  the  stomach  contents  and  feces,  there  are  long 
bacilli  or  leptothrix  which  come  from  incrustations  on  the  teeth  and 
which  resemble  very  closely  the  lactic  acid  bacilli ;  a  point  of  distinc- 
tion is  the  fact  that  the  former,  when  Lugol's  solution  is  added  are 
stained  violet,  while  the  latter  undergo  no  change  in  color. 

DIGESTION  IN  THE  STOMACH. 

As  soon  as  the  food  enters  the  stomach,  it  begins  to  undergo  the 
most  thorough  chemical  changes,  by  which  its  identity  becomes  largely 
destroyed  through  the  activity  of  hydrochloric  acid,  pepsin,  rennin, 
and  the  more  recently  discovered  fat-splitting  ferment  which,  many 
still  think,  comes  through  the  pylorus  from  the  duodenum.  But  before 
we  proceed  to  the  consideration  of  the  secretion  of  these  chemical 
agencies  and  the  factors  which  influence  them,  as  well  as  the  changes 
taking  place  in  the  food,  we  must  acquire  an  understanding  of  the 
divisions  and  motions  of  the  stomach.  This  organ  consists  of  two 
portions,  which  are  anatomically  and  functionally  distinct — ^the 
fundus,  or  main  stomach,  and  the  antrum,  where  the  greater  part  of 
the  digestion  takes  place.  The  large  stomach,  if  we  may  call  it  such 
after  the  manner  of  herbivora,  enables  mankind  to  partake  of  large 
portions  of  food,  and,  acting  as  a  reservoir,  allows  small  portions  to  be 
passed  into  the  antrum,  where  after  hours,  perhaps,  they  are  digested 


k 


32  DISEASES   OF   THE   DIGESTIVE   TRACT 

and  partially  absorbed.  The  muscles  of  this  former  part  of  the  organ 
are  weak,  have  no  power  to  produce  peristaltic  action,  and  simply  in 
the  normal  individual  keep  up  a  tension  on  the  contained  food,  vary- 
ing with  the  amount  of  food  present ;  if  there  is  no  food,  in  a  state  of 
fasting  the  stomach  is  collapsed  like  a  bag  and  the  inner  walls  lie 
in  contact  with  each  other.  Whenever  food  is  taken,  the  muscles  con- 
tract only  sufficiently  to  keep  up  a  moderate  pressure  on  the  content 
equal  to  only  6-8  cm.  of  water,  but,  when  this  is  acquired,  remain 
quiescent.  Thus  in  the  fundus  the  food  rests  in  layers  exactly  in  the 
order  in  which  it  was  eaten. 

In  the  antrum,  however,  affairs  are  different.  This  portion  of  the 
organ,  when  the  stomach  is  moderately  filled,  as  shown  by  the  radio- 
grams, points  upward  and  the  pylorus  forms  its  highest  point,  and 
therefore  it  is  very  improbable  that  the  viscus  is  emptied  by  gravity, 
but  by  the  strong  muscular  action  of  the  antrum;  hence  this  is  pro- 
vided with  powerful  muscles,  which  terminate  in  a  strong  ring,  the 
pylorus.  This  motion  consists  of  peristaltic  waves,  which  begin  at 
the  border  of  these  two  portions  of  the  stomach,  at  once  or  within  a 
few  minutes  after  the  food  is  taken,  continue  with  the  greatest  regu- 
larity, pass  toward  the  pylorus,  and  end  only  w^hen  the  last  frag- 
ment of  food  has  passed  into  the  intestine.  This  peristalsis  is  so 
powerful  that  the  pressure  is  vastly  increased  over  that  of  the  fundus 
and  deep  furrows  are  formed,  the  first  of  which  at  a  beginning 
wave  may  be  so  deep  that  a  complete  separation  of  the  two  parts  of 
the  stomach  takes  place.  The  result  of  these  forcible  contractions  is 
that  the  fluid  spurts  through  the  pylorus  into  the  duodenum  and  can 
often  be  heard  with  a  stethoscope  over  that  part ;  hence  the  functions 
of  the  stomach  may  be  said  to  be  made  up  of  the  low,  but  steady, 
pressure  of  the  fundus,  the  peristalsis  of  the  antrum,  and  the  syn- 
chronous secretion  of  the  gastric  juice.  Thus  we  may  explain  the  con- 
tinuance of  salivary  digestion  for  two  hours  or  more  after  the  food 
enters  the  stomach,  since  the  interior  of  the  content  of  the  fundus 
does  not  come  in  contact  with  the  secreting  gastric  walls,  and  a  free 
hydrochloric  acid  reaction  may  disappear  in  a  gastric  content  when 
allowed  to  stand,  for  only  in  this  receptacle  has  complete  mixing 
taken  place.  It  is  clear  that  only  small  fractions  can  be  subjected  to 
the  full  action  of  the  gastric  juice  at  a  time  and  in  the  midst  of  an 
active  digestion;  while  the  content  of  the  antrum  may  be  acid,  that 
of  the  interior  of  the  fundus  may  be  neutral  or  even  alkaline. 

When,  however,  any  of  the  food  is  fully  liquefied  and  digested,  it 
is  forced  through  the  open  pylorus  into  the  duodenum ;  solid  and  un- 


THE   PHYSIOLOGY   OF   DIGESTION  33 

digested  portions  meet  an  unyielding  exit,  and  remain  to  be  still  fur- 
ther kneaded  and  mixed  with  the  gastric  juice.  Thus  the  pylorus  has 
the  power  of  selection,  and  allows  only  those  portions  which  are  thor- 
oughly digested  to  pass  through.  Further  than  this,  the  duodenum 
also  has  a  control  over  the  opening  of  the  pylorus;  when  the  small 
intestine  is  empty,  the  pylorus  remains  open,  which  explains  the  ease 
with  which  bile-stained  contents  may  be  washed  from  the  fasting 
stomach  and  why  the  Einhorn  aspiration  duodenal  catheter  passes  so 
readily  through  the  pylorus.  But  chemical  influences  also  regulate 
this  mechanism ;  when  fat  or  acid,  such  as  the  acid  gastric  juice,  comes 
in  contact  with  the  mucous  membrane  of  the  duodenum,  the  pylorus 
closes  for  a  longer  or  shorter  period,  dependent  on  the  amount.  An- 
other curious  circumstance  is  the  fact  that,  if  the  stomach  is  full  of 
food  and  a  glass  of  water  is  taken,  this  runs  along  the  lesser  curvature 
from  cardia  to  pylorus  without  in  any  way  mixing  with  the  food  in 
the  fundus;  at  first  it  is  mixed  with  that  in  the  antrum  to  a  certain 
extent,  but  soon  almost  pure  water  passes  through  the  exit.  A  dilu- 
tion of  the  solid  food  in  the  stomach  does  not,  then,  take  place  when 
water  is  drunk  with  the  meal,  and  the  regulation  of  the  opening  and 
closing  goes  on  just  the  same,  whether  fluids  are  taken  with  the  meal 
or  not.  This  pyloric  reflex  plays  a  very  important  part  in  our 
digestion ;  we  have  yet  no  measure  of  the  digestibility  of  food.  Fats, 
we  know,  leave  the  stomach  very  slowly,  and  we  also  know  that  food 
finely  divided  is  mixed  with  the  gastric  juice  more  readily  and  quickly 
and  passes  sooner  into  the  duodenum  than  coarser  food;  but  is  this 
always  a  desideratum?  In  this  way  food  improperly  digested  may 
reach  the  intestine  and  thereby  throw  an  extra  burden  upon  it.  Our 
sense  of  gastric  discomfort  is  very  acute,  but  we  know  nothing 
of  duodenal  indigestion,  except  by  its  results.  On  the  other  hand, 
when  the  digestion,  peristalsis,  or  absorption  in  the  duodenum  is  de- 
layed or  impaired,  it  may  cause  a  prolonged  closure  of  the  pylorus 
and  thereby  produce  stasis  and  decomposition,  or  too  prolonged  secre- 
tion of  gastric  juice  in  an  otherwise  healthy  stomach.  Boldyreff,  too, 
has  observed  that,  if  an  individual  take  a  large  portion  (300  c.e.)  of  a 
liquid  fat  like  olive  oil,  the  pylorus  opens,  allowing  the  duodenal  con- 
tents to  recede  into  the  stomach.  This  peristaltic  action  of  the 
antrum  plays  a  very  important  part  in  the  act  of  vomiting.  At 
first  the  muscular  tone  of  the  fundus  relaxes,  leaving  its  walls 
flabby;  the  cardia  opens  and  the  waves  of  the  antrum  continue, 
but  against  a  closed  pylorus  and  a  relaxed  fundus,  in  which  way 
contents  of  the  stomach,  perhaps  aided  by  the  pressure  of  the  dia- 


34  DISEASES   OF   THE   DIGESTIVE   TRACT 

phragm  and  the  abdominal  walls,  with  mouth  open,  posterior  nares  and 
glottis  closed,  as  in  swallowing,  are  forced  out  of  the  mouth.  The 
center  of  all  these  coordinated  acts  is  in  the  medulla. 

The  peristaltic  waves  of  the  antrum  are  also,  to  a  certain  extent,  sub- 
ject to  our  sensations.  When  the  stomach  is  under  obser%^ation  with 
the  fluorescent  screen  and  the  x-rays,  it  is  found  that  any  unfavorable 
influence,  like  worry  or  grief,  causes  a  cessation  of  these  waves  and 
their  continuance  takes  place  only  when  the  mind  is  restored  to  its 
normal  calm.  We  have  long  known  that  psychic  influences  may 
cause  a  marked  change  in  the  secretory  functions  of  the  stomach,  but 
here  is  marked  proof  that  they  also  act  on  its  motility,  and  efforts  to 
establish  a  correct  mental  status  is  fully  as  legitimate  in  tjie  treat- 
ment of  functional  dyspepsias  as  selecting  the  proper  medicament, 
and  often  greatly  more  effective.  As  to  the  rapidity  with  which  dif- 
ferent varieties  of  food  leave  the  stomach,  it  may  be  stated  as  a  gen- 
eral principle,  with  some  qualifications  in  particular  cases,  that  the 
carbohydrates,  farinaceous  foods,  and  vegetables,  which  arouse  the 
secretion  of  but  little  gastric  juice,  leave  the  organ  very  promptly; 
that  meat  remains  much  longer,  especially  when,  as  is  customary,  it 
contains  fat,  while  pure  fat,  and  especially  the  firmer  fats,  like  tallow 
and  lard,  remain  the  longest.  Another  element  is  injected  into  the 
slow  departure  of  fats,  and  that  is  the  delayed  secretion  of  gastric 
juice  and  the  slowing  of  the  liquefaction  of  the  solid  parts  of  the 
food;  both  these  factors  can  be  used  in  the  diet  of  those  suffering 
from  impaired  motility  of  the  stomach  and  hypersecretion. 

We  have  already  spoken  of  the  excitation  of  the  flow  of  gastric 
juice  by  means  of  mastication  and  the  sense  of  gratified  taste,  but 
this  is  not  the  only  means  by  which  this  secretion  may  be  aroused; 
even  the  sight  or  odor  of  food  causes  a  flow,  but  weariness  and  lack 
of  appetite  retard  the  flow.  Then,  again,  the  amount,  but  according 
to  Bickel  not  the  composition,  of  the  gastric  juice  varies  with  the 
character  of  the  food  or  beverage.  Water  induces  the  production 
of  a  small  amount  of  juice,  milk  still  more,  next  in  the  series  comes 
bread,  and  meat  demands  and  produces  the  greatest  flow  of  all ;  this 
is  true  of  meat  for  any  period,  but  bread  and  milk  change  their 
relative  places  after  the  first  hour,  so  that  for  the  entire  period  of 
digestion  the  amount  produced  by  bread  is  less  by  one-half  than 
the  amount  produced  by  milk.  When  liquid  food  is  introduced  di- 
rectly into  the  stomach  through  a  tube,  no  secretion  is  aroused,  but, 
if  beef  extract  is  brought  in  contact  with  the  walls  of  the  antimm,  a 
lively  secretion  in  the  fundus  of  the  stomach  takes  place;  this  is  sup- 


THE   PHYSIOLOGY   OF   DIGESTION  35 

posed  to  be  due  to  the  absorption  by  which,  in  its  passage  through 
the  walls,  a  hormone  is  released  or  formed  which  excites  the  flow 
through  the  blood.  As  fat  retards  peristalsis  of  the  stomach,  so  it 
diminishes  secretion,  and  thus  justifies  the  use  of  yolk  of  egg  and 
cream  in  eases  of  hypersecretion  just  as  the  beef  extract  has  a  rational 
basis  for  its  use  in  achylia.  The  amount  of  gastric  juice  secreted 
daily  reaches  1,500  c.c,  which  is  of  great  interest  to  us  when  in  cases 
of  achylia  we  attempt  by  the  use  of  hydrochloric  acid  and  pepsin  to 
replace  it;  this,  as  can  be  seen  at  a  glance,  is  a  Sisyphus'  task,  best 
honored  by  its  avoidance.  Pure  gastric  juice,  which  we  never  find 
clinically,  but  which  Umber  and  Bickel  have  obtained  from  humans 
with  a  double  fistula  in  the  esophagus  and  stomach,  contains  hydro- 
chloric acid  to  the  amount  of  0.46  to  0.58  per  cent,  an  amount  much 
greater  than  we  have  previously  believed  possible,  but  the  smaller 
limit  of  0.35  per  cent  has  been  dependent  on  the  neutralizing  influence 
of  the  saliva  which  has  been  swallowed,  as  well  as  by  the  mucus  of  the 
stomach  and  the  diluting  effect  of  both  these  and  food  remnants.  We 
have  heard  endless  discussions  of  hyperchlohydria  and  hypochlohydria, 
but  from  careful  experiments  it  is  pretty  fully  established  that  the 
concentration  of  the  mineral  acid  in  the  secretion  remains  the  same 
under  all  conditions,  and  what  we  are  dealing  with  is  a  hyper  or 
hyposeeretion  of  gastric  juice.  We  may  never  hope  to  obtain  a  juice 
with  this  high  acidity  clinically  for  the  following  reasons :  a  diminished 
secretion,  with  the  usual  albumin  containing  test  breakfast,  diminishes 
the  relative  acidity,  or  a  greater  amount  of  mucus  may  be  secreted  by 
the  stomach,  producing  the  same  result,  or  an  increased  secretion  of 
the  alkaline  pyloric  secretion  has  the  same  effect. 

Another  function  of  the  hydrochloric  acid,  in  addition  to  the  di- 
gestive action,  is  to  check  the  growth  of  bacteria;  whether  it  can 
destroy  these  microorganisms  after  they  have  once  entered  the  stomach 
seems  to  be  still  lacking  proof,  and  that  the  acid  can  exert  any  influ- 
ence in  the  intestine,  as  some  claim,  is  negatived  by  the  utter  lack  of 
correspondence  between  the  amount  of  indol,  a  product  of  intestinal 
bacteria  in  the  feces,  with  the  presence  or  absence  of  this  acid  in  the 
stomach.  This  acid  undoubtedly  prevents  the  fermentation  and  putre- 
faction of  food  which  would  inevitably  take  place,  if  the  reaction 
were  alkaline,  during  its  long  stay  in  the  stomach,  aided  by  the  com- 
parative sterility  of  all  foods  due  largely  to  cooking.  With  a  hydro- 
chloric acid  concentration  of  less  than  0.08  per  cent  the  action  of 
the  lactic  acid  bacillus  on  sugar  is  distinctly  stayed,  and  with  one  of 
less  than  0.02  per  cent  decidedly  delayed.     Now,  these  acidities  may 


36  DISEASES  OP   THE  DIGESTIVE   TRACT 

be  found  on  the  outer  layer  of  the  food  in  the  fundus  and  also  in 
the  antrum,  but  in  the  center  of  the  mass  of  food,  as  stated,  the  re- 
action may  be  alkaline,  and,  since  the  gastric  juice  does  not  penetrate 
it,  the  probable  reason  why  in  this  locality  no  more  active  growth  of 
bacteria  takes  place  is  the  short  delay  of  the  food  in  the  stomach. 
Even  when  there  is  a  marked  growth  of  these  minute  objects,  it  is 
usually  of  the  fermentative  kind  and  not  of  the  putrefactive ;  in  fact, 
the  former  are  prohibitive  of  the  latter,  and  it  is  curious  in  marked 
gastric  stasis  to  see  sarcinge,  which  act  on  protein,  flourish  as  long  as 
hydrochloric  acid  exists,  but  disappear  as  soon  as  lactic  acid  replaces 
it.  "We  have  already  mentioned  the  pyloric  secretion  of  the  stomach 
as  affecting  the  general  acidity  of  the  gastric  juice;  this  contains  no 
acid,  but  much  mucus,  is  alkaline,  and  its  secretion  seems  to  be  con- 
tinuous, but  amounts  to  only  a  few  cubic  centimeters  per  hour. 
Much  importance  has  been  ascribed  to  this  secretion  on  account  of 
its  influence  in  neutralizing  overacid  gastric  contents,  and,  in  fact,  it 
does  seem  to  flow  more  rapidly  when  the  fundus  secretion  with  its  acid 
content  comes  in  contact  with  the  antrum.  In  the  antrum,  too,  some 
absorption  takes  place,  which  is  limited  to  salts,  sugar,  and  peptones 
dissolved  in  water,  but  not  water  itself,  unassoeiated  with  these  sub- 
stances. Other  functions  of  the  hydrochloric  acid  are  to  activate  the 
pepsin,  which  is  first  secreted  in  an  inactive  form,  to  split  the  cane 
sugar  into  grape  sugar  and  fruit  sugar,  in  which  forms  alone  they  can 
be  utilized,  and  to  stimulate  the  secretion  of  the  pancreatic  juice;  in 
fact,  so  important  is  the  last  function  that,  when  we  have  an  achylia 
gastriea  (lack  of  gastric  secretion),  we  are  very  apt  to  have  also  an 
impairment  of  the  pancreatic  secretion,  a  veritable  achylia  panere- 
atica.  The  main  function  of  the  hydrochloric  acid  is,  however,  with 
the  aid  of  pepsin,  another  secretion  from  the  stomach,  to  convert 
protein  to  peptone,  and  gelatin  and  elastin,  connective  tissue,  to  their 
corresponding  peptones,  Erepsin,  which  still  further  carries  on  the 
digestion  to  amino-acids,  is  said  to  be  found  in  the  pyloric  secretion. 
The  pepsin  is  found  both  in  the  fundus  and  in  the  pyloric  secretion, 
and  is  much  more  persistent  than  the  acid.  In  fact,  whenever  hydro- 
chloric acid  is  found  in  gastric  contents,  this  always  assures  us  that 
pepsin  is  present  in  sufficient  quantities  to  carry  on  the  digestion  per- 
fectly, and  only  in  those  eases  where  the  acid  is  absent  (achylia,  gastric 
cancer,  and  atrophic  gastritis)  is  it  necessary^  to  test  for  pepsin.  The 
rennin  is  always  secreted  as  an  inactive  substance,  which  becomes 
active  through  the  agency  of  the  hydrochloric  acid ;  its  action  is  to 
coagulate  milk,  and  its  production  always  suffers  when  the  secretion 


THE   PHYSIOLOGY   OF   DIGESTION  37 

of  the  acid  suffers  diminution.  Still,  its  detection  has  never  been  of 
very  great  diagnostic  value,  and  there  are  many  who  contend  that 
pepsin  and  rennin  are  identical  substances.  The  stomach  steapsin 
must  also  be  mentioned,  which  has  the  power  to  split  fat  into  glycerin 
and  fatty  acid  in  an  acid  medium,  particularly  if  the  fat  be  emulsi- 
fied; but,  since  we  have  learned  how  readily  the  duodenal  content, 
with  its  pancreatic  steapsin,  can  come  through  the  pylorus  if  the 
stomach  contains  an  excessive  amount  of  fat,  the  origin  of  this  ferment 
in  the  stomach  becomes  more  doubtful.  Taken  altogether,  we  see 
that  half  the  burden  of  the  digestion  of  protein  is  borne  by  the 
stomach,  and,  while  the  pancreas  can  vicariously  undertake  the  entire 
process,  the  frequency  with  which  diarrheas  occur  when  the  gastric 
digestion  is  impaired — as  in  achylia  gastriea,  for  instance — indicates 
what  a  burden  is  thrown  on  this  secondary  means  of  the  digestion  of 
protein  and  how  often  it  fails  to  sustain  it. 

INTESTINAL  DIGESTION. 

As  the  motor  functions  play,  perhaps,  even  a  more  important  part 
than  the  purely  chemical  change  in  the  food,  we  will  consider  them 
first.  To  do  this  intelligently,  we  must  divide  the  intestinal  tract 
into  two  portions — the  small  and  the  large  intestine.  The  motions 
of  the  former  are  of  a  double  nature.  First,  the  rhythmic  segmenta- 
tions which  Cannon  has  so  well  shown  in  his  zooscope,  consisting  of 
contractions  at  short  intervals  from  each  other,  whose  sole  object 
seems  to  be  to  mix  the  food  thoroughly  in  the  intestine  and  not  in  any 
way  to  advance  it  along  the  canal;  these  continue  while  there  is  food 
which  incites  them  in  the  gut,  occurring  ten  to  twelve  times  per 
minute,  and  each  one  lasting  five  to  six  seconds.  Second,  there  is 
the  true  peristalsis,  which  moves  the  food  forward  toward  the  anus, 
and  consists  of  a  contraction  at  some  point  where  the  stimulus  is 
applied,  beginning  at  that  part  nearest  the  stomach,  and  the  re- 
laxation of  the  succeeding  portion  of  the  intestine,  by  which  the  con- 
tent of  that  section  is  forced  forward.  These  peristaltic  movements 
arise  from  special  stimuli,  and  can  be  regarded  as  reflex  in  their  char- 
acter. Under  normal  conditions  these  stimuli  proceed  from  the  in- 
testinal contents,  and  are  of  mechanical  character,  as  rubbing  or  dis- 
tention of  the  walls,  but  chemical  influences  also  play  a  part,  as  the 
presence  of  organic  acids,  fatty  acids,  and  gases.  From  this  latter 
fact  arises,  no  doubt,  the  empirical  use  of  citric  acid  in  lemons,  malic 
acid  in  apples,  and  lactic  acid  in  sour  milk  as  means  of  stimulating  the 


38  DISEASES  OF   THE   DIGESTIVE   TRACT 

peristalsis.  These  movements  are  always  toward  the  anus,  and  anti- 
peristalsis  does  not  take  place  here.  As  a  great  curiosity,  there  exists 
the  so-called  Exner  needle  reflex,  by  which,  when  a  needle  or  other 
sharp  object  enters  the  intestine  and  its  point  pricks  the  mucous  mem- 
brane, it  causes  a  relaxation  of  the  adjacent  portion,  so  that  the 
needle  falls  in  a  hollow  and  the  peristaltic  action  carries  the  blunt 
end  forward;  this  is  accomplished  by  the  layer  of  muscle  known  as 
the  muscularis  mucosae.  The  passage  of  food  through  the  entire  small 
intestine  requires  from  three  and  a  half  to  six  hours ;  vegetable  food, 
and  especially  that  rich  in  cellulose,  passes  much  more  quickly  than 
meats,  and  the  greater  use  of  meat  as  an  article  of  food  at  the  present 
day  may  account  for  the  increase  of  constipation.  When  the  small  in- 
testine is  empty,  it  lies  still,  except  that  every  one  and  a  half  to 
two  and  a  half  hours  a  series  of  active  movements  take  place,  a 
fact  known  to  the  laity  without  its  true  explanation,  who  describe 
it  humorously  as  the  intestines  chasing  each  other  in  search  of  food. 
All  these  movements  are  automatic,  yet  under  the  control  of  certain 
influences,  among  which  we  may  mention  the  increase  of  peristalsis 
due  to  lack  of  oxygen  or  increase  of  carbon  dioxide  in  the  blood  and 
mental  influence  from  the  brain,  such  as  anxiety  or  fear,  as  the  diar- 
rhea which  occurs  in  some  patients  only  when  they  are  far  from  a 
water  closet. 

In  the  colon  we  have  a  change  in  the  movements  in  that  the  rhythmic 
segmentations  and  the  peristalsis  occur  only  in  those  parts  where  the 
content  is  still  fluid  or  semisolid — that  is  in  the  cecum  and  ascending 
colon.  Here  for  the  first  time  we  come  on  the  reversed  peristalsis, 
whose  object  apparently  is  to  keep  the  contents  longer  for  more  thor- 
ough manipulation,  where  they  remain,  by  the  way,  the  longest  time 
— viz.,  ten  to  fourteen  hours.  Whether  this  is  a  true  antiperistalsis, 
or  due  to  periodic  contraction  rings  in  the  transverse  colon  or  splenic 
flexure,  has  not  yet  been  determined.  As  soon  as  the  contents  reach 
the  transverse  colon  they  begin  to  thicken  and  then  the  fecal  cylinder 
is  forced  forward  by  tonic  contractions,  lasting  three  seconds  and 
occurring  every  eight  hours,  which  are  excited  by  the  entrance  of  new 
food  or  by  defecation.     This  is  well  illustrated  by  Fig.  8. 

The  feces  collect  in  the  sigmoid  flexure,  and,  when  the  mass  has 
reached  a  certain  volume  it  is  forced  into  the  rectum  by  contractions 
of  the  colon.  When  the  feces  enter  the  rectum,  whether  by  contact 
with  its  walls  or  by  distention  is  not  known,  we  become  aware  of  its 
presence  and  the  reflex  for  defecation  is  aroused.  If  this  call  is  not 
obeyed,  it  seems  that  a  return  to  the  sisrmoid  may  take  place.     When 


THE   PHYSIOLOGY   OF   DIGESTION 


39 


obeyed,  the  rectum  contracts,  both  sphincters  relax,  and  defecation 
takes  place.  After  defecation  takes  place,  which  usually  empties  the 
contents  of  the  sigmoid  and  the  descending  colon,  the  floor  of  the 
lesser  pelvis  is  raised  by  the  levator  ani  and  the  sphincters  assume 
their  normal  state  of  contraction.  This  reflex  center,  which  controls 
the  whole  process,  is  situated  in  the  sacral  portion  of  the  spinal  cord, 


Vove< 


fhrs. 


^ 


rhn. 


r" 


iOhrs. 


Fig.  8. — Normal  movements  of  the  contents  of  the  colon,  according  to  Hertz. 

with  perhaps  a  secondary  one  in  the  lumbar  portion.  What  in- 
terests us  more  is  the  fact  that,  when  the  center  in  the  sacral  portion 
is  destroyed  by  disease,  the  external  sphincter  remains  permanently 
relaxed,  while,  when  the  destruction  is  above  the  lumbar  part,  it  re- 
mains in  a  state  of  tonic  contraction  and  can  not  be  influenced  by 
voluntary  effort.     In  both  cases  the  rectum  is  without  sensation,  and 


40  DISEASES  OF   THE   DIGESTIVE   TRACT 

stool  occurs  wholly  by  reflex  action.  The  patients  have  desire  for  a 
movement,  but  from  time  to  time,  when  the  rectum  is  sufficiently  filled, 
there  follows  a  spontaneous  emptying  without  the  knowledge  of  the 
individual. 

Sensation  of  the  intestinal  canal  above  the  sphincters,  as  is  found 
in  the  skin,  is  wanting,  and  it  is  interesting  to  note  in  operations  on 
this  canal  what  a  slight  degree  of  anesthetization  is  demanded,  and 
how  quickly  more  ether  must  be  given  as  soon  as  the  closure  of  the  ab- 
dominal wall  is  attempted.  Apparently  the  mucous  membrane  is 
sensitive  only  to  distention — by  gas,  to  pinching,  and  to  pathological 
changes,  such  as  anemia,  cramp,  and  inflammation.  The  movements 
of  the  tract,  both  the  segmentation  and  the  peristalsis,  can  be  con- 
trolled by  drugs — as  atropine,  which  diminishes  the  excitability  of  the 
mesenteric  plexus  and  slows  these  movements ;  adrenalin,  which  excites 
the  nerves  which  check  such  motions  of  the  gut ;  nicotine  and  caffeine, 
which  excite  the  motor  apparatus  even  to  cramps;  and  by  laxatives 
which  stimulate  peristalsis  by  irritation  of  the  mucous  membrane  or 
increase  the  speed  of  the  contents  through  the  canal  by  preventing 
the  absorption  of  the  water.  The  latter  action  is  caused  by  salts.  In- 
flammation of  the  peritoneum  (peritonitis)  also  causes  cessation  of 
peristalsis. 

By  digestion  in  the  stomach  the  food  is  prepared  for  further  action 
of  digestive  agencies  in  the  intestine,  and  the  chief  of  these  changes 
are  the  liquefication  of  the  connective  tissue  of  meat,  of  the  gluten  of 
bread,  and  the  middle  layer  of  vegetable  foods.  The  only  substance 
which  is  really  liquefied  or  in  solution  is  the  protein,  and  this  to  only 
fifty  per  cent.  While  the  gastric  juice  in  itself  has  no  action  on 
starch,  it  has  been  shown  by  myself  and  others  that  the  diastatic 
changes,  due  to  the  saliva,  continue  for  one  to  two  hours  after  the 
food  enters  the  stomach.  The  reason  for  this  at  that  time  was  not 
known,  but  now  we  know  that  it  is  due  to  the  arrangement  of  the  food 
in  the  stomach  in  layers,  so  that  the  interior  of  the  food  mass  does  not 
come  in  contact  with  the  hydrochloric  acid,  which  in  any  considerable 
concentration  inhibits  starch  digestion,  for  one  or  more  hours  after 
the  food  is  taken.  Besides  converting  the  food  to  the  consistency  of 
gruel,  the  stomach  corrects  the  temperature  of  too  hot  or  too  cold 
food,  and  dilutes  and  renders  bland  substances  which  are  too  con- 
centrated or  too  irritating  (pepper,  mustard,  etc.),  before  they  enter 
the  duodenum.  Naturally  the  contents,  entering,  are  strongly  acid, 
but,  due  to  the  closure  of  the  pylorus  until  this  acidity  can  be  over- 
come by  the  pancreatic  juice,  succus  entericus.  and  other  agencies,  the 


THE   PHYSIOLOGY   OF   DIGESTION  41 

acidity  in  the  intestine  can  never  exceed  a  certain  concentration,  and  it 
is  supposed,  where  the  acidity  is  much  diminished  in  the  stomach, 
that  the  food  enters  the  intestine  much  more  quickly  and  in  a  less 
liquefied  form.  Substances  which  produce  an  irritation  of  the  in- 
testinal mucous  membrane  and  thus  cause  diarrhea,  also  induce  a  long 
closure  of  the  pylorus.  Furthermore,  owing  to  the  inhibitive  action 
of  the  hydrochloric  acid  on  bacterial  growth,  the  food  enters  the 
duodenum  practically  sterile. 

The  secretion  of  the  pancreatic  juice,  partially  stimulated  by  the 
act  of  eating,  is  much  more  strongly  aroused  by  the  entrance  of  the 
acid  gastric  contents  into  the  duodenum.  In  addition  to  the  hydro- 
chloric acid,  fatty  acids  and  soaps  stimulate  by  their  presence  the 
secretion  of  this  digestive  juice,  but  neither  alkalies  nor  neutral  fats 
have  the  same  effect.  The  character  of  the  secretion  differs  accord- 
ing to  the  character  of  the  food,  but  with  the  ordinary  mixed  diet  the 
amount  is  about  500  c.c.  per  day.  It  is  alkaline  from  the  presence  of 
0.4^0.5  per  cent  of  sodium  carbonate,  and  contains  enzymes  for  all 
three  classes  of  food;  the  diastase,  which  digests  both  cooked  and  un- 
cooked starch,  like  the  pytalin,  but  more  energetically;  the  tryp- 
sin, not  secreted  in  active  form,  but  as  a  proferment,  which  re- 
quires enterokinase,  which  is  also  produced  by  the  cells  of  the 
duodenum,  only  when  pancreatic  juice  is  contained  in  it,  that  dis- 
solves and  hydrolyzes  all  albuminous  substances,  except  connective 
tissue,  which,  if  not  digested  by  the  gastric  juice,  passes  the  whole 
length  of  the  canal  and  is  found  in  the  feces;  and  some  other  less 
important  protein  bodies.  This  digestion  of  protein  is  carried  much 
farther  than  in  the  stomach — that  is,  to  the  formation  of  amino-acids, 
from  which  the  albumins  of  the  blood  are  elaborated ;  and  last,  the 
lipase,  which  converts  fats  into  fatty  acids  and  glycerin,  or  directly  to 
soaps  when  abundant  alkali  is  present.  The  action  of  the  last-men- 
tioned ferment  is  vastly  increased  by  the  presence  of  bile,  especially 
of  its  bile  salts.  Lecithin,  which  has  now  become  a  much  used  remedial 
agent,  is  also  split  by  the  steapsin.  The  bile  acts  not  only  as  an 
aid  to  fat  digestion,  but  also  contains  manj^  inert  substances,  like 
cholesterin,  biliary  coloring  matter,  and  a  nucleoalbumin,  all  of  which 
have  no  function  in  digestion ;  this  secretion  is  produced  continuously, 
but  flows  from  its  reservoir,  the  gall  bladder,  only  in  answer  to  certain 
stimuli,  fats  or  albumoses,  into  the  duodenum,  "We  may  see  some 
physiological  reason  in  this  for  the  empirical  use  of  olive,  oil  to  increase 
the  flow  of  bile  through  the  common  duct,  and  thereby  prevent  stag- 
nation, as  well  as  to  sweep  back  the  bacteria  which  are  supposed  to 


42  DISEASES  OP   THE  DIGESTIVE   TRAt!T 

invade  the  gall  bladder  from  the  intestine.  The  amount  of  bile  se- 
creted daily  amounts  to  700-800  c.e.,  and,  outside  of  its  sodium 
taurocholate  and  glycocholate,  which  activate  the  lipase,  has  no  di- 
gestive action,  but  holds  the  fatty  acids  and  soaps  in  solution,  which 
is  of  immense  advantage  to  absorption  of  fats,  a  fact  easily  proven  by 
the  fatty  stool  when  the  bile  fails  wholly  or  in  part  of  entrance  into 
the  alimentary  cajial. 

The  succus  entericus  interests  us  chiefly  on  account  of  several 
enzymes  Avhich  it  contains,  not  found  elsewhere,  but  having  a  marked 
influence  on  the  general  digestion.  For  instance,  we  find  here  in- 
vertin,  which  splits  cane  sugar  into  grape  sugar  and  fruit  sugar; 
maltase,  which  breaks  up  malt  sugar,  the  result  of  the  diastatic  diges- 
tion of  ptyalin  and  the  diastase  of  the  pancreas,  into  grape  sugar ;  and 
lactase,  which  splits  the  milk  sugar  into  grape  sugar  and  galactose. 
It  is  of  practical  importance  that  the  last  named  occurs  regularly  only 
in  the  nursing  child  and  disappears  when  the  child  takes  up  a  mixed 
diet,  but  will  return  in  the  adult  when,  for  any  reason,  he  is  kept  on  a 
milk  diet.  Still,  we  may  account  for  the  fact  that  the  adult  cannot 
utilize  milk  as  well  as  the  infant,  and  that  adults  often  respond  to  an 
exclusive  milk  diet  with  diarrhea,  by  the  supposition  that  temporarily 
no  lactase  is  present  in  the  intestine  of  the  adult.  ]\luch  less  impor- 
tant, and  as  yet  only  physiological  curiosities,  are  erepsin,  which 
splits  the  albumoses  and  peptones  into  the  amino-acids  and  nuclease, 
which  thoroughly  disintegrates  nucleoproteid  and  nucleinic  acid,  and 
possibly  has  some  influence  on  uric  acid  metabolism.  We  are  some- 
times surprised  when  the  small  intestine  is  opened,  as  is  common  in 
the  operation  of  gastrojejunostomy',  to  find  so  little  material  in  the 
intestine,  considering  the  enormous  amount  of  the  digestive  fluids 
which  are  poured  into  it.  Apart  from  the  short  period  of  fasting 
which  precedes  this  operation,  we  also  have  to  take  into  account  the 
small  portions  of  food  which  are  passed  into  the  intestine  at  a  time  by 
the  regulatory  action  of  the  pylorus,  the  rapid  progress  through  the 
small  intestine,  and  the  absorption  which  begins  in  the  upper  portions 
of  the  canal  by  which  a  large  portion  of  the  properly  digested  content 
is  rapidly  removed. 

As  soon  as  progress  from  the  large  to  the  small  intestine  takes 
place  through  the  ileocecal  valve,  we  find  the  contents  begin  to  thicken, 
and  that  but  few  food  fragments,  recognizable  to  the  naked  eye,  are 
found  in  them;  the  microscope  shows  a  few  meat  fibers,  some  starch 
granules  inclosed  in  their  cellulose  coverings,  as  well  as  some  free 
granules  and  some  fat,  but  no  amino-acids.     The  colon  secretes  no  di- 


I 


THE   PHYSIOLOGY  OF   DIGESTION  43 

gestive  ferments,  but  the  remnants  of  the  duodenal  secretion  are  suf- 
ficient to  continue  the  process  of  digestion,  at  least  in  the  cecum  and 
the  ascending  colon,  until  the  rapid  thickening  of  the  content  brings 
even  this  to  a  halt.  Beginning  with  the  cecum,  we  find  an  active  bac- 
terial action  taking  place  which  can  split  fat,  digest  a  portion  of  the 
cellulose  still  remaining,  check  the  process  of  fermentation  hitherto 
predominant,  and  even  destroy  its  products.  This  has  a  double  sig- 
nificance in  that,  though  pancreatic  juice  may  fail  to  enter  the  intestine 
on  account  of  obstruction,  fat  will  be  well  digested  and  cellulose  be 
so  well  disintegrated  that  the  natural  stimulus  of  the  colon  is  want- 
ing and  constipation  results.  Our  experience  with  nutritive  enemata 
shows  us,  however,  that  all  the  products  of  digestive  action  in  the 
colon  are  not  destroyed  by  bacteria,  else  no  nutriment  would  be  ab* 
sorbed  from  such  a  method  of  sustaining  life.  Absorption,  a  func- 
tion of  the  intestine  equally  important  with  digestion,  shows  a  pre- 
dilection for  certain  substances;  for  instance,  water  is  eagerly  taken 
up,  and  even  by  excessive  drinking  of  water  we  cannot  make  the 
stools  liquid.  Sodium  chloride  is  readily  absorbed,  but  sodium  and 
magnesium  sulphate  are  not  at  all,  or  to  the  slightest  degree,  ab- 
sorbed, but  rather  withdraw  water  from  the  fluids  of  the  body,  on 
which  is  based  their  laxative  action.  Calcium  also  is  another  sub- 
stance which  seems  to  undergo  no  absorption,  except  such  as  may 
undergo  conversion  in  the  stomach  to  the  chloride,  and,  in  fact,  is 
freely  eliminated  by  the  colon. 

Probably  maltose  is  the  only  double  sugar  which  can  be  absorbed 
without  being  split,  and  there  is  ample  evidence  that  it  is  split, 
before  it  reaches  the  liver,  to  grape  sugar.  Of  protein  we  can  say 
that  only  the  minutest  portions  are  absorbed  in  any  other  form  than 
as  amino-acids.  The  body  can  build  up  its  own  structure  only  with 
like  albumin,  and  to  do  this  all  foreign  albumins  must  lose  utterly 
their  own  identity  before  they  can  be  utilized,  and  this  is  accomplished 
by  converting  them  to  the  simplest  ingredients  with  Avhich  we  are 
familiar.  There  is  ample  evidence  of  this  in  the  rapid  elimination  by 
the  kidney  of  a  foreign  albumin  like  that  of  egg  when  injected,  or,  as 
in  some  diseased  conditions  of  the  intestines,  when  absorbed  before 
completely  broken  up.  It  goes  without  saying  that,  from  recent  in- 
vestigations, it  is  fully  established  that  all  fats  must  be  split  before 
absorption,  but  all  need  not  be  converted  into  soaps,  since,  if  some 
are,  their  solution  in  water  will  carry  the  fatty  acids  contained  in  the 
emulsion  through  the  villi  to  the  circulation,  while,  in  this  journey, 
all  the  acids  find  glycerin  enough  to  pair  with  them  and  appear  once 


44  DISEASES   OF   THE   DIGESTIVE   TRACT 

more  as  globules  of  neutral  fat.  Paraffin  and  vaseline  pass  through 
the  canal  without  saponification,  and  from  this  is  derived  their  value 
in  constipation,  since  they  are  not  absorbed.  Hematin  is  very  poorly 
absorbed,  and  hence  the  care  to  be  employed  in  preventing  the  pa- 
tient from  taking  meat  or  any  of  its  products  when  a  chemical  test  for 
blood  is  to  be  made  in  the  stool.  Of  the  gases,  carbon  dioxide  is  readily 
absorbed,  marsh  gas  much  less  so,  and  hydrogen  the  least  of  all ;  what 
influence  this  may  have  on  flatulence,  since  all  these  gases  are  produced 
from  the  food  by  bacteria  or  fermentative  action,  is  not  definitely 
known. 

On  account  of  the  very  important  part  which  the  bacteria  play  in 
the  intestine,  particularly  the  lower  section,  a  little  more  attention 
must  be  paid  them.  It  has  been  demonstrated  that  one-third  of  the 
total  dried  feces  consists  of  bacteria,  of  which  99  per  cent  are 
found  dead  in  the  stool.  These,  however,  at  some  period  during  their 
passage  through  the  canal  must  have  lived,  so  that  the  colon  eon- 
tents  are  subjected  to  the  action  of  at  least  128,000,000,000  of  bacteria; 
their  action  is  chiefly  exerted  in  the  cecum  and  ascending  colon,  and 
it  is  probable  that  the  beginning  thickening  of  the  contents  in  the 
transverse  colon  is  responsible  for  the  death  of  the  majority  of  them. 
It  is  peculiar  that  in  the  small  intestine,  apart  from  the  lowest  section 
of  the  ileum,  the  bacteria  do  not  flourish,  partly  due,  no  doubt,  to 
the  inhibitive  action  of  the  hydrochloric  acid  of  the  stomach,  which 
has  already  been  mentioned,  to  the  rapid  absorption  of  the  food  ele- 
ments by  which  food  for  their  growth  is  removed,  and  the  well-known 
fact  that  a  normal  mucous  membrane  can  destroy  the  microorganisms 
which  come  in  contact  with  it.  This  power,  however,  is  limited  to 
the  normal  intestine,  and,  when  there  is  the  slightest  hindrance  to 
the  passage  of  food  through  the  duodenum,  or  its  mucous  membrane 
becomes  diseased  in  the  slightest  degree,  then  there  is  abundant  groAvlh 
of  these  minute  organisms,  and  it  is  probable  that  many  instances  of 
cholecystitis  are  due  to  their  invasion  of  the  common  duct  and 
journey  hence  to  the  gall  bladder.  There  is  a  vast  number  of  varieties 
of  these  growths,  which  vary  in  preponderance  according  to  the  food 
taken,  but  we  are  chiefly  interested  in  the  bacillus  coli  communis, 
which  is  usually  in  excess  on  a  mixed  diet,  and  the  bacterium  lactis 
cerogenes  on  a  milk  diet,  as  well  as  less  numerous  yeast  spores,  butyric 
acid  bacilli,  and  sarcinae.  The  chief  source  of  putrefaction  is  the 
bacillus  putrificus  and  bacillus  sporogenes.  While  in  the  small  in- 
testine (lower  portion)  the  chief  activity  of  the  microbes  is  upon  the 
carbohydrates,  producing  carbon  dioxide,  lactic,  butyric,  and  acetic 


THE   PHYSIOLOGY   OF   DIGESTION  45 

acids,  hydrogen,  and  marsh  gas,  below  the  ileocecal  valve  the  action 
is  upon  the  proteins,  evolving  ammonia,  sulphuretted  hydrogen,  indol, 
skatol,  phenol,  and  kresol ;  furthermore,  by  their  activities  bilirubin  is 
reduced  to  stercobilin,  which  gives  the  color  to  feces,  and  cholesterin 
to  coprosterin.  The  former  substances  are  absorbed  and  rendered 
innocuous  by  union  with  sulphuric  acid,  and  on  them  is  based  the 
whole  theory  of  autointoxication  of  intestinal  origin.  The  amount 
of  these  noxious  substances  produced  is  so  slight,  however,  that  it  is 
incredible  that  they  can  produce  a  deleterious  action  on  the  body. 
]\Iuch  more  are  we  led  to  believe  that  this  activity  of  the  organisms 
is  of  value,  since  it  converts  a  portion  of  the  cellulose  into  substances 
available  to  the  body  and  for  which  no  digestive  ferment  exists,  and 
also  produces  elements  which  stimulate  peristalsis  and  aid  defecation. 
At  least,  we  can  not  quite  hold  with  ]\Ietschnikoff,  that  the  putrefactive 
products  are  responsible  for  arteriosclerosis  and  early  old  age.  The 
intestinal  tract  is  looked  on  as  possessing  the  functions  of  digestion 
and  absorption,  but  we  must  not  lose  sight  of  the  fact  that  it  also  has 
the  power  of  elimination,  as  is  proven  by  the  presence  of  no  incon- 
siderable amount  of  feces  in  the  fasting  individual;  furthermore,  we 
have  the  instances  of  elimination  of  mercury  by  the  colon  and  of  urea 
in  case  of  damaged  kidneys.  The  stool  of  the  fasting  is  made  up  of 
the  residue  of  the  bile,  the  biliary  acids  having  only  digestive  power, 
and,  being  reabsorbed,  of  the  eliminative  products  of  the  intestinal 
walls,  consisting  chiefly  of  salts,  fats,  desquamated  epithelial  cells, 
mucus,  and  the  characteristic  nucleoproteid  of  the  inner  intestinal 
coat  found  in  every  stool.  Hence  it  would  appear  that  two-thirds  of 
the  fecal  nitrogen  arises  from  intestinal  eliminative  products  and  not 
from  food  remnants.  It  is  true  that  the  food  remnants  practically 
never  fail  in  the  stool,  but  the  amount  varies  very  much  with  the  char- 
acter and  preparation  of  the  food ;  for  instance,  and  this  is  of  practi- 
cal importance  in  the  treatment  of  constipation,  the  food  element  in 
the  stool  largely  increases  when  uncooked  or  underdone  connective 
tissue  (scraped  beef,  rare  beef),  mutton  or  beef  tallow  and  raw  veg- 
etables (celery,  radishes,  lettuce,  etc.),  are  taken  as  food,  on  account 
of  the  large  cellulose  content,  and,  on  account  of  their  lack  of  diges- 
tion, a  larger  portion  of  the  otherwise  digestible  and  absorbable  food 
goes  with  them. 


CHAPTER  III 
EXAMINATION  OF  THE  PATIENT 

This  term  is  advisedly  used  rather  than  examination  of  the  stomach 
or  gastrointestinal  tract,  for  we  must  at  first  examine  all  the  organs 
of  the  body  rather  than  the  organs  alone  in  which  we  are  interested, 
since  nothing  could  be  more  unsatisfactory  for  the  physician  nor  more 
disastrous  for  the  patient  than,  when  we  find  an  abnormality  in  the 
functions  of  any  part  of  the  alimentary  tract,  to  be  satisfied  with  this 
discovery.     For  instance,  we  may  find  that  a  so-called  gastric  catarrh 
owes  its  existence  to  an  incompetent  cardiac  valve,  and  all  efforts  to 
overcome  the  secondary  effect  of  this  will  be  unavailing  unless  we 
direct  our  attention  to  the  original  lesion;  hence  a  careful  examina- 
tion of  the  heart  is  always  to  be  made.     Again,  we  find  a  deficiency 
of  gastric  juice,  or  even  a  complete  achylia,  in  an  individual  who  has 
been  losing  flesh  and  perceptibly  growing  weaker  without  any  definite 
cause ;  here  a  careful  examination  of  the  lungs  will  often  demonstrate 
a  so-called  pretubercular  stage  of  pulmonary  consolidation  without 
the  classical  symptoms  of  the  fully  established  disease.     Or,  again, 
we  find  fullness  after  eating,  eructations,  and  sometimes  slight  at- 
tacks of  pain  of  short  duration,  with  absolutely  no  abnormality  of 
the  stomach  that  can  be  discovered,  but  a  careful  palpation  of  the 
gall  bladder  region  will  elicit  tenderness,  and  often  an  examination 
of  the  urine  will  show  a  slight  trace  of  bile,  a  feature  much  more 
important,  in  my  mind,  than  yellowing  of  the  sclera,  and  we  have 
demonstrated  a  cholecystitis  as  the  cause  of  the  reflex  stomach  sjinp- 
toms.     In  fact,  following  the  old  French  axiom,  ' '  cherchez  la  femme, ' ' 
whenever  gastric   symptoms   are  present   without   demonstrable   ab- 
normalities in  the  stomach  itself,  look  for  the  reflex.     Always  bearing 
in  mind  the  normal  conditions,  we  may  examine  the  stomach,  either 
directly  by  determining  its  position  and  size  as  well  as  the  character 
of  its  contents,  or  we  may  examine  it  indirectly  in  determining  the 
presence  of  extensive  connective  tissue  fragments  or  chemical  blood 
in  the  stool,  the  former  of  which  indicates  a  deficient  gastric  juice, 
and  the  latter,  if  symptoms  pertain  to  the  epigastrium,  gastric  hemor- 
rhage. 

46 


EXAMINATION   OF   THE   PATIENT  47- 

The  direct  method  of  examination  includes  inspection,  palpation, 
percussion,  auscultation,  diaphanoscopy,  and  gastroscopy,  the  latter 
two  now  little  used,  and  the  more  recent  and  much  more  valuable 
rontgen  ray  examination.  In  addition  to  these,  we  have,  of  course, 
the  examination  of  the  gastric  contents  at  stated  intervals  after  the 
ingestion  of  certain  foods,  but  the  last  has  been  often  disappointing 
to  those  who  expected  to  make  diagnoses  on  the  finding  of  these  chem- 
ical examinations  alone.  Where  the  intelligence  of  the  patient  is 
evident,  the  history  of  the  present  and  previous  illnesses  on  which 
the  former  may  be  based  is  undoubtedly  valuable,  and  should,  of 
course,  always  be  investigated,  but  it  is  astounding  how  often  cul- 
tivated people  can  tell  you  little  or  nothing  of  the  length,  frequency, 
and  severity  of  an  attack  of  pain,  but  have  clear  and  well-defined 
opinions  with  reference  to  what  foods  agree  and  what  do  not,  and 
among  the  latter  you  find  those  which  science  tells  you  are  the  most 
easily  digested.  In  a  clinic  practice,  which  usually  deals  with  the 
most  ignorant,  a  history  is  much  less  valuable;  former  illness  and 
suffering  are  usually  lost  sight  of  in  the  present  discomfort,  in  the  de- 
tailing of  which  by  the  patient  the  important  features  are  ignored  and 
the  unimportant  dwelt  upon,  and  only  by  leading  questions  can  what 
is  sought  by  the  physician  be  obtained,  a  method  always  subject  to 
great  error  in  an  oversusceptible  grade  of  society.  Thus  the  physician 
is  driven  to  the  knowledge  acquired  by  his  eyes,  ears,  finger  tips,  and 
such  aids  as  chemical  tests  afford  him.  As  to  the  order  in  which  such 
an  examination  should  be  conducted,  every  medical  man  is  a  law 
unto  himself,  provided  that  nothing  escape  his  attention.  The  history 
may  be  learned  in  a  short  biography  of  the  patient  from  the  cradle 
to  the  present  illness,  with  its  symptoms,  which  will  often  include 
a  lot  of  irrelevant  matter,  or  the  method  of  Cabot  may  be  followed, 
which  lends  itself  admirably  to  clinic  examinations,  and  consists  of 
learning  the  leading  symptoms;  from  that  we  branch  out  to  learn 
its  relation  to  conjoint  symptom,  its  probable  cause,  its  connection 
with  previous  attacks  of  illness,  and  its  possible  dependence  on  a 
family  trait  or  disease. 

Then  the  physical  examination  should  follow,  in  which  every  organ 
of  the  body  should  be  interrogated,  and  the  gastric  contents  withdrawn, 
if  the  patient  can  tell  you  what  he  ate,  when,  and  the  approximate 
amount.  The  results  of  the  chemical  examination  will  often  give  one 
a  better  knowledge  of  the  state  of  the  digestion  than  bread  and  water 
fare,  for  reasons  stated  before,  and  the  removal  is  rarely  difficult, 
except  within  an  hour  after  meat  is  eaten,  when  the  fragments  may 


48  DISEASES   OF   THE   DIGESTIVE   TRACT 

stop  the  eye  of  the  tube.  The  urine  is  to  be  examined  briefly  for  bile 
pigment  (cholecystitis),  indican  (intestinal  stasis),  diazo  reaction 
(malignant  disease),  and  Ehrlich  reaction  (hepatic  disease).  If  any- 
thing out  of  the  ordinary  be  found,  a  portion  of  the  twenty-four 
hours'  urine  may  be  examined  at  the  next  visit,  at  which  time  the 
meat-free  stool  may  be  examined  for  chemical  blood,  or  the  Schmidt 
or  other  simple  diet  stool  examined  for  deranged  gastric  or  intestinal 
digestion.  At  the  second  consultation,  too,  it  is  often  found  conven- 
ient to  have  the  patient  come  without  breakfast,  but  having  eaten  what 
is  termed  a  hearty  meal  the  evening  before,  to  which  has  been  added 
some  boiled  rice  and  raisins,  when  the  stomach  is  washed  out  for  the 
stasis  test,  and  then  the  Boas-Ewald  test  breakfast  may  be  given  if 
certain  points,  like  absence  of  hydrochloric  acid  (free)  in  the  con- 
tents at  the  first  examination,  demand  it.  The  x-ray  picture  or  pic- 
tures, if  thought  necessary,  are  usually  made  by  special  appointment 
with  the  rontgenologist  at  still  another  period.  This  is  the  usual  ex- 
perience both  in  clinics  and  in  private  practice,  but,  w^here  time  presses 
and  the  patient  can  be  communicated  with  beforehand,  he  can  come 
w^ith  no  breakfast  after  the  Riegel  meal  of  the  night  before,  with  his 
stool  in  a  ]\Iason  jar,  and  all  can  be  accomplished  at  one  sitting. 

THE  HISTORY. 

While  acknowledging  the  frailties  of  this  method  of  examination, 
still  it  must  be  conceded  that  much  valuable  information  can  be  ob- 
tained, and,  whenever  a  patient  comes  to  us  complaining  of  symptoms 
directed  toward  the  digestive  organs,  we  must  make  a  careful  inquiry 
into  each  feature  of  his  discomfort,  and  try  to  make  him  particularize 
and  not  be  content  that  he  describe  his  difficulty  as  ' '  stomach  trouble, ' ' 
a  term  generally  used  by  the  laity  to  designate  anything  occurring  in 
the  abdomen.  IMany  times  the  patient's  description  of  his  departure 
from  health  has  a  particular  significance  when  absolutely  nothing  ob- 
jective can  be  discovered,  and  the  more  bizarre  his  tale  and  the  more 
inconsistent  wdth  all  laws  of  digestion,  as  determined  by  experiment, 
the  more  valuable  it  is,  because  it  indicates  so  strongly  a  functional 
affection.  The  history  concerns  itself,  first,  with  general  conditions 
and  previous  diseases  which  may  have  some  causative  connection,  and, 
second,  with  the  analysis  of  the  present  difficulty. 

General  Conditions. — Age  and  sex  play  their  part.  In  puberty,  as 
well  as  at  the  climacteric,  functional  gastric  disorders  are  very  com- 
mon; gastric  cancer,  however,  though  it  may  rarely  occur  in  youth,. 


EXAMINATION   OF   THE  PATIENT  49 

generally  occurs  after  fifty.  The  idea  that  gastroduodenal  ulcer,  a 
safe  term  on  account  of  the  hairline  anatomical  difference  in  the  site 
and  similarity  of  symptoms,  is  confined  to  youth  has  never  been  sub- 
stantiated and,  if  one  may  judge  from  clinical  experience,  confirmed 
by  operation,  men  and  women  suffer  in  equal  measure  from  this  dis- 
ease. Women,  however,  are  unquestionably  more  prone  to  gastric 
neuroses,  enteroptosis  and  cholecystitis,  while  stomach  symptoms  are 
complained  of  whenever  the  generative  organs  are  diseased,  and  func- 
tional gastric  difficulty  is  always  exaggerated  during  the  menstruation. 
It  is  also  kno^^^l  that  when  a  splanchnoptosis  is  present,  though  it  is 
congenital  and  has  existed  from  birth,  the  first  symptoms  with  refer- 
ence to  the  entire  tract  (eructations,  constipation,  etc.)  come  on  at 
the  time  of  puberty.  Intestinal  catarrhs  usually  appear  in  both  men 
and  women  at  the  period  of  greatest  exertion,  the  one  to  succeed  in 
business  and  the  other  to  attain  a  place  in  society,  which  means, 
usually,  irregular  and  rapid  eating.  The  constipation  of  young  girls 
may  come  on  in  connection  with  chlorosis,  while  the  colon  catarrh  of 
women  usually  dates  from  some  confinement  (tears  and  displacement 
of  the  uterus).  Inattention  to  the  act  of  defecation  on  the  part  of 
young  girls  on  account  of  modesty,  false  though  it  may  be,  often 
starts  a  train  of  intestinal  symptoms  which  last  long  after  common 
sense  has  replaced  this  false  modesty. 

Heredity. — There  is  very  little  evidence  that  diseases  of  the  diges- 
tive tract  are  in  any  way  transmitted  from  parent  to  child.  It  is 
sometimes  observed  that  the  condition  known  as  status  enteropticus, 
where  there  is  a  general  ptosis  of  the  abdominal  organs,  may  be  found 
in  two  generations,  but,  as  Stiller  has  remarked,  it  should  rather  be 
considered  as  an  asthenia  universalis  congenita,  and  hence  the  in- 
heritance of  general  lack  of  physique,  rather  than  an  inherent  weak- 
ness of  the  digestive  organs.  Then,  too,  we  have  instances  where  so- 
called  nervous  dyspepsia  may  be  found  in  two  or  three  generations, 
but  it  is  as  likely  to  manifest  itself  in  some  other  form  of  nervous 
weakness  in  the  next  generation  as  in  a  weakness  of  the  digestive 
organs,  and  hence  is  not  peculiar  to  those.  There  has  also  been  some 
question  of  the  heredity  of  cancer  of  the  tract,  but  about  all  the  evi- 
dence collected,  apart  from  the  well-known  frequency  of  this  dis- 
ease in  the  different  generations  of  the  Napoleon  family,  which  in- 
dicated a  transference  from  parent  to  child,  is  contained  in  the  statis- 
tics of  the  Zurich  clinic,  where,  of  138  cases  of  cancer  of  the  digestive 
organs,  8  per  cent  of  the  victims  had  had  ancestors  who  were  also 
afflicted  with  cancer  of  similar  organs.     It  is  much  more  probable  that, 


50  DISEASES   OF   THE   DIGESTIVE   TRACT 

if  we  take  into  account  cancer  of  all  organs,  we  may  find  this  heredity 
much  more  pronounced  than  when  we  confine  it  to  the  digestive 
tract. 

Occupations  of  certain  kinds  are  especially  prone  to  digestive  dis- 
eases, such  as  the  bartender,  who,  from  the  temptation  to  indulgence 
in  alcoholics,  is  frequently  subject  to  chronic  gastritis,  either  from 
direct  irritation  of  the  stomach  or  from  the  cirrhosis  of  the  liver, 
which  so  often  accompanies  it;  cooks,  too,  are  said  to  be  much  more 
liable  to  gastric  ulcer,  whether  from  the  frequent  tasting  of  food,  as  is 
supposed,  or  from  the  heat  in  which  they  usually  work,  cannot  be  told. 
Workers  in  lead,  such  as  painters  and  typesetters,  are  always  con- 
stipated, and  directly  or  indirectly  are  sufferers  from  varioug  gastric 
difficulties. 

Then,  too,  we  have  the  workers  in  soft  phosphorus,  the  match- 
makers, who,  apart  from  the  so-called  ''phossy  jaw,"  are  very  apt, 
on  account  of  the  almost  universal  inflammation  of  the  digestive  tract, 
to  suffer  from  vomiting  and  more  or  less  bloody  discharges.  Thanks 
to  the  efforts  of  our  legislators,  both  in  this  country  and  abroad,  the 
use  of  soft  phosphorus  for  this  purpose  either  has  been  or  soon  will 
be  forbidden.  Laborers  engaged  in  the  reduction  of  ores,  milliners 
handling  artificial  flowers,  and  others  often  suffer  from  diarrheas 
from  the  absorption  of  arsenic,  which,  through  its  elimination  by  the 
intestinal  mucous  membrane,  produces  marked  hyperemia,  hemor- 
rhage, and  sometimes  ulcerations.  The  same  thing  is  also  true  of 
those  who  work  with  mercury,  and  it  has  not  been  unknown  among 
those  who  take  calomel  internally  or  use  corrosive  sublimate  externally, 
though  the  use  of  these  drugs  is  much  less  common  by  the  medical  pro- 
fession. 

Duration  of  Illness. — Here  must  be  taken  into  consideration  whether 
the  illness  is  acute  or  chronic,  whether  it  is  persistent  or  recurring, 
or  periodical.  Gastric  ulcer  is  noted  for  its  apparent  cures,  which 
may  occur  several  times  under  the  * '  ulcer  treatment ' '  and  still  return ; 
whether  the  patient  is  free  from  difficulty  during  the  interval,  a 
peculiarity  of  cholelithiasis,  which  notoriously  produces  stomach  symp- 
toms like  pressure  in  the  epigastrium,  sometimes  pain  extending 
through  to  the  back,  M'hich  is  not  severe  and  is  often  relieved  by  free 
eructations  of  gas,  must  be  ascertained.  Appendicitis,  too,  is  dis- 
titiguished  by  its  intervals  of  comparative  freedom  from  discomfort. 
Gastric  crises,  intermittent  gastric  hypersecretion,  often  associated 
"\fidth  migraine  and  the  temporary  digestive  disturbances,  associated 
with  the  menstruation  in  women,  are  all  noted  for  the  regularity  with 


EXAMINATION   OP   THE  PATIENT  51 

which  they  appear  at  definite  intervals.  IMore  recently  a  periodicity 
has  been  noticed  in  the  attacks  of  pain  in  duodenal  ulcer. 

Former  Sicknesses. — The  medical  profession  is  all  too  ready  to 
associate  earlier  diseases  in  a  causal  relation  with  later  ones,  and 
perhaps  often  without  sufficient  ground;  but,  when  patients  with  gas- 
tric symptoms  describe  an  earlier  threatened  pulmonary  tuberculosis 
or  recovery  from  the  same,  we  may  regard  an  achylia  as  the  direct 
outcome  of  it,  or,  when  patients  of  well  advanced  years  describe  an 
early  gastric  ulcer,  we  may  well  look  very  carefully  for  malignant 
disease.  The  association  between  malignant  disease  and  injury  is 
not  so  clearly  proven,  yet  many  instances  have  come  to  me  where 
there  was  a  close  connection,  the  most  recent  an  annular  carcinoma 
of  the  descending  portion  of  the  colon,  six  years  after  a  carriage  ac- 
cident in  which  three  ribs  were  broken  on  the  left  side,  but  with  in- 
testinal symptoms  dating  back  four  years  or  more  from  discovery  of 
the  lesion.  A  history  of  an  acute  heart  attack,  with  many  years  of 
comfort,  may  well  make  us  look  sharply  for  so-called  "gastric 
catarrh"  and  cardiac  decompensation.  A  history  or  suspicion  of  pre- 
vious syphilis  may  cause  attacks  of  epigastric  pain  to  be  assigned  to 
their  proper  category — manifestations  of  spinal  sclerosis — which  will 
usually  be  verified  by  loss  of  reflexes  and  lack  of  coordination.  A 
history  of  previous  "nervous  prostration,"  treated  at  home  or  in  a 
sanatorium,  will  often  minimize  your  patient's  tale  of  great  gastric 
suffering,  and  you  will  easily  verify  a  nervous  dyspepsia,  though  the 
former  can  hardly  be  said  to  be  a  cause  of  the  latter,  but  another 
manifestation  of  the  same  general  weakness. 

Causation. — Patients  often  have  a  ready  explanation  for  their  attack 
of  ' '  stomach  trouble, ' '  as  they  call  it,  and  most  often  it  is  some  inoffend- 
ing  article  of  food  that  is  held  guilty.  It  will  often  be  found,  how- 
ever, that  the  meal  of  which  this  food  formed  a  part  was  eaten  hastily 
or  in  a  state  of  mental  agitation,  or,  more  often,  that  slight  dis- 
turbance had  existed  for  a  long  time  previous  to  which  no  attention 
had  been  paid,  but  everything  dated  from  the  period  when  the  at- 
tack had  been  most  severe.  It  is  curious  to  note  how  in  the  patients ' 
minds  gastric  cancer,  which  is  of  very  slow  growth,  dates  from  a 
definite  period  when  they  had  a  particularly  sharp  attack  of  indi- 
gestion ;  hence  it  is  not  wise  to  put  too  much  dependence  on  the  pa- 
tient's  explanation  of  the  cause  of  his  illness,  or  we  may  be  led  into 
error.  That  an  accident  may  cause  gastric  ulcer  seems  well  estab- 
lished, and  has  twice  come  under  my  own  observation  in  so  close  a 
connection  that  there  could  be  no  doubt  in  mv  ovm  mind.     There  is 


52  DISEASES   OF   THE   DIGESTIVE   TRACT 

no  question,  too,  that  spoiled  food  may  excite  an  intestinal  catarrh, 
which  often  gains  the  more  dignified  term  of  "ptomaine  poisoning," 
something  entirely  different  by  the  way,  which  catarrh,  neglected,  may 
easily  become  chronic. 

Dependence  of  Digestive  Symptoms  on  Coexisting  Diseases. — 
Dysphagia  and  regurgitation  are  sometimes  produced  by  the  pres- 
sure of  an  aneurism  on  the  esophagus,  and  Professor  Oser,  of  the 
Vienna  polyclinic,  used  to  show  a  pathological  specimen  in  which  death 
had  occurred  from  the  rupture  of  an  aneurism  into  the  esophagus 
of  a  patient  into  whose  stomach  only  lack  of  time  had  deterred  Oser, 
the  day  before,  from  introducing  the  tube  to  explain  the  patient's  ob- 
scure gastric  symptoms.  Gastric  symptoms,  like  heartburn  and  vom- 
iting, may  arise  from  cancer  of  the  ascending  colon  or  from  that  of 
the  splenic  flexure.  Chronic  appendicitis  may  affect  not  only  the 
motility  of  the  stomach,  but  also  its  secretion,  usually  by  lessening  the 
one  and  increasing  the  other.  For  a  long  time  cirrhosis  of  the  liver 
manifests  itself  by  gastric  symptoms,  which,  as  stated,  are  also  caused 
by  cholelithiasis.  When  menstruation  alone  may  change,  under 
physiological  conditions,  the  secretory  functions  of  the  stomach,  we 
may  expect  many  functional  disorders  of  digestion  at  the  periods  of 
pregnancy  and  the  climacteric.  These,  too,  we  actually  find,  and  treat- 
ment directed  toward  the  stomach  itself  at  these  periods  is  much  less 
effective  than  that  directed  toward  uterus  and  adnexa.  Raising 
a  flexed  uterus  has  often  cheeked  vomiting,  and  removal  of  a  small 
ovarian  cyst  has  relieved  gastric  discomfort.  As  all  physicians  know, 
nausea,  eructations,  vomiting,  and  diarrhea  may  be  the  first  symptoms 
of  a  nephritis  when  uremia  is  present,  as  well  as  very  common  symp- 
toms of  an  acute  indigestion.  In  a  much  less  violent  form  these  symp- 
toms may  be  present  for  a  long  period  in  chronic  nephritis,  and  nat- 
urally are  the  symptoms  to  which  the  patient's  attention  is  directed, 
rather  than  to  a  slight  edema  or  an  increase  of  urine.  While  the  ex- 
amination of  the  urine  quickly  clears  up  this  confusion,  we  must  not 
lose  sight  of  the  fact  that,  where  there  is  gastric  stasis  or,  as  some 
say,  intestinal  autointoxication,  a  trace  of  albumin,  which  is  often  of 
the  nucleo  variety,  must  not  be  misinterpreted.  Reflex  digestive  dis- 
turbances are  often  associated  with  cystitis  and,  particularly,  with 
retention  of  urine,  due  to  enlarged  prostate  in  men  and  ureteral  stone 
or  kink  causing  pyelitis  or  pyelonephritis  in  women.  In  a  recent  ease, 
whenever  the  pelvis  would  fill  with  urine  (hydronephrosis),  there 
occurred  a  persistent  diarrhea.  It  is  astonishing  sometimes  how 
quickly  the  relief  from  these  urinary  disorders  clears  up  the  gastric 


EXAMINATION   OF   THE   PATIENT  53 

symptoms.  We  have  also  heard  very  much  concerning  the  gastric 
symptoms  associated  with  prolapsed  or  movable  kidney,  and  many  a 
suspension  of  the  wandering  kidney  has  been  done  without  relief 
of  the  stomach  difficulties.  In  all  probability  Stiller  solved  the 
problem  when  he  found  that  prolapse  of  the  stomach  was  associated 
with  the  dislocated  kidney  and  caused  the  digestive  symptoms. 
Pharyngitis,  particularly  the  chronic  form,  often  produces  a  feeling 
of  nausea,  which  is  attributed  to  the  stomach,  and  efforts  to  clear  the 
throat,  associated  with  gagging,  may  bring  on  vomiting.  Further- 
more, those  who  suffer  from  emphysema,  either  from  the  persistent 
cough,  which  through  the  diaphragm  must  keep  the  stomach  in  a  state 
of  unrest,  or  from  engorgement  of  the  stomach  walls  with  blood  on 
account  of  the  impaired  circulation  through  the  lungs,  often  have 
associated  stomach  symptoms.  It  is  frequently  difficult,  too,  to  dis- 
tinguish the  pseudoangina  pectoris,  due  to  distention  of  the  stomach 
with  gas  and  pressure  on  the  diaphragm,  from  real  angina;  usually 
an  attack  of  the  former  comes  on  after  eating,  and  of  the  latter  after 
exercise. 

Neuroses  may  cause  all  sorts  of  gastric  symptoms  from  pain — 
gastralgia,  as  it  is  sometimes  called — to  prolonged  vomiting,  while  the 
same  functional  nervous  disease  produces  all  forms  of  irregularities 
in  the  gastric  secretion  from  hyperchlohydria  to  a  complete  achylia; 
associated  with  them  in  etiology  may  be  found  also  hypersecretion, 
both  alimentary  and  continuous.  A  whole  chapter  might  be  written 
on  nervous  dyspepsia  and  its  relation  to  certain  psychoses.  Many 
patients  date  their  whole  train  of  symptoms  from  grief  or  fright,  and 
one  of  the  early  humorists  describes  the  manifestations  of  overstudy 
in  words  which  are  as  true  today  as  when  written,  and,  as  today,  the 
greater  stress  is  laid  on  those  pertaining  to  the  stomach.  Still,  we 
should  not  be  content  to  lightly  make  the  diagnosis  of  gastric  neurosis 
without  a  most  careful  and  searching  examination  for  some  physical 
cause  for  the  "neurosis."  Sometimes  it  is  a  blood  disturbance  like 
chlorosis,  sometimes  a  chronic  ulcer  without  acute  symptoms,  rarely 
a  genital  difficulty  like  inflammation  of  the  deep  urethra  or  the 
seminal  vesicles  and,  last  but  not  least,  intestinal  parasites,  especially 
teniae.  It  is  also  noted  that  patients  suffering  from  long  gastric  dis- 
tress become  neurotic,  weep  readily,  suffer  from  insomnia,  and  find 
it  very  difficult  to  give  the  examining  physician  a  clear  idea  of  the 
origin  of  their  illness,  which,  w^hen  elicited,  points  clearly  to  symptoms 
pertaining  to  the  digestive  organs,  but  which  has  been  overshadowed 
by  their  other  sufferings.     IMany  digestive  disorders  are  dependent 


54  DISEASES   OF   THE   DIGESTIVE   TRACT 

on  blood  diseases,  such  as  pernicious  anemia,  which  almost  invariably 
produces  an  achylia  so  complete  that,  in  conjunction  with  the  evident 
appearance  of  cachexia,  I  have  known  distinguished  surgeons  to  op- 
erate for  malignant  disease  of  the  stomach. 

j\Iariy  metabolic  diseases,  like  diabetes,  produce  gastric  symptoms 
like  bulimia  or  "ox  hunger,"  gastric  crises,  and  gastralgias,  while 
gouty  diathesis  causes  the  "gouty"  stomach  of  the  English,  and  Base- 
dow's disease  may  produce  a  persistent  diarrhea. 

Infectious  diseases  also  induce  digestive  disorders.  The  effect  of 
pulmonary  tuberculosis  has  already  been  mentioned  and  the  prodromal 
stage  of  typhoid  may  be  characterized  only  by  malaise  and  gastric 
symptoms.  ' 

Emacfation. — It  may  be  readily  seen  that  loss  of  weight  may  ac- 
company gastric  disorders  from  physiological  causes,  such  as  loss  of 
appetite,  restricted  diet,  and  fear  of  eating — in  fact,  in  the  eyes  of 
the  laity,  dieting  usually  means  semistarvation — so  that  emaciation 
of  itself  does  not  necessarily  mean  organic  disease,  but  in  organic  dis- 
ease of  the  gastrointestinal  tract,  especially  when  associated  with 
pain,  one  notices  a  disproportionate  loss  of  flesh.  AYith  malignant 
disease  of  the  esophagus  and  stomach,  the  loss  is  sometimes  startling 
and  rapid;  in  the  latter  case  not  only  when  there  is  produced  nar- 
rowing of  the  pylorus,  associated  wnth  great  pain  and  vomiting,  but 
also  when  the  growth  is  found  in  the  body  of  the  organ,  producing 
neither  of  these  symptoms.  Such  emaciation  may  be  found  where  the 
food  is  ample  to  meet  the  demands  of  the  economy,  and,  under  these 
conditions,  great  and  rapid  loss  of  weight  are  very  suggestive  of 
cancer  of  the  stomach,  or  in  some  instances  of  other  parts  of  the 
tract.  That  a  part  of  this  loss  of  weight  is  due  to  the  vomiting  and 
lessened  food  consumption  is  shown  by  the  very  slow  loss  when  gas- 
trojejunostomy has  been  performed  for  relief  of  symptoms  of  stenosis 
in  cancer  of  the  pylorus.  Curiously  enough,  cancer  of  the  lower 
intestinal  tract  does  not  produce,  in  any  marked  degree,  such  loss  of 
flesh.  We  may  often  see  patients  with  cancer  of  the  rectum  or  sig- 
moid in  a  very  good  state  of  nutrition,  and  be  first  apprised  of  the 
dangerous  character  of  their  malady  by  a  sudden  obstruction  or  a 
persistent  diarrhea. 

Character  of  Food  and  Manner  of  Life. — ]\Iany  digestive  disorders 
are  brought  about  by  improper  cooking  and  unsuitable  articles  of  food. 
Few  of  us  have  escaped  at  times  the  frying-pan  and  hot  soda  biscuit; 
heavy  gravies  and  greasy  hashes  have  proved  many  a  patient's  Avater- 
loo.     Nor  is  the  damage  always  to  be  attributed  to  the  character  of 


'  EXAMINATION    OF   THE   PATIENT  55 

the  food  or  its  preparation;  rapid  eating  and  insufficient  mastication 
have  made  the  American  race  a  nation  of  dyspeptics,  while  the  intro- 
ductory glass,  of  ice  water  is  tolerated  by  no  other  nation.  Then,  too, 
the  after-the-theater  supper,  eaten  after  a  hard  day's  work  and  three 
hours  in  a  stuffy  theater,  often  puts  an  end  to  the  tolerance  of  a  much- 
abused  digestion  and  a  surgeon  removes  the  rebellious  appendix.  Ex- 
cessive use  of  tobacco,  tea,  coffee,  and  condiments  often  play  their 
part,  and  should  always  be  inquired  into. 

Mutual  Reaction  of  Different  Diseased  Parts  of  the  Digestive  Tract 
on  Each  Other.— The  presence  of  cholelithiasis  is  generally  recog- 
nized as  producing  a  hypersecretion  of  the  stomach,  which  manifests 
itself  as  ' 'heartburn, ' '  and  is  one  reason  why  so  many  affections  of 
the  gall  bladder  impress  themselves  on  the  laity  and  often  on  physi- 
cians as  gastric  disorders.  Then,  again,  a  gastric  achylia  is  often  as- 
sociated with  a  pancreatic  achylia  even  if  the  latter  is  not  the  direct 
outcome  of  the  former,  and  associated  with  both  we  have  a  diarrhea, 
often  termed  lienteric.  Chronic  appendicitis,  furthermore,  may  pro- 
duce a  hypersecretion  of  the  stomach,  and  recent  observers  think  that 
it  causes  gastric  hypotony  as  well. 

SUBJECTIVE  SYMPTOMS. 

Appetite  and  Sense  of  Hunger. — While  appetite  and  hunger  are 
physiologically  different,  patients  do  not  distinguish  between  these 
two,  and  clinically  there  is  little  gained  by  differentiation,  since  they 
go  hand  in  hand.  Sometimes  one  is  told  by  patients  that  they  have 
a  feeling  of  faintness  at  regular  intervals,  which  is  a  distorted  sense 
of  hunger,  but  that  no  food  tastes  good,  and  hence  there  is  no  in- 
centive to  more  than  superficially  satisfy  the  hunger,  a  statement 
which  is  to  be  interpreted  as  a  lack  of  appetite.  These  two  conditions 
are  associated  with  all  kinds  of  disturbances  of  digestion,  and,  if  by 
questions  one  can  learn  that  sufficient  intervals  elapse  between  taking 
food,  they  are  usually  the  earliest  and  most  reliable  of  the  symptoms 
which  indicate  a  disease  of  the  digestive  tract,  whether  functional  or 
organic.  There  are  people,  however,  who  are  addicted  to  "nibbling," 
taking  some  food  almost  every  hour  during  their  waking  moments, 
and  with  these  lack  of  appetite  is  to  be  expected  and  has  no  significance. 
The  appetite  in  those  suffering  from  digestive  disorders  may  be  per- 
sistent, erratic,  varying  from  time  to  time,  or  may  be  entirely  absent. 
The  loss  of  appetite,  too,  is  not  always  to  be  ascribed  to  disease  of 
the  digestive  tract  alone,  as  witness  its  presence  in  many  febrile  dis- 


56  DISEASES   OF   THE   DIGESTIVE   TRACT 

turbances  and  in  chlorosis.  Not  only  may  the  appetite  be  absent,  but 
there  may  also  be  utter  disgust  for  certain  forms  of  food,  as  for 
meat  in  the  sufferer  from  gastric  cancer.  Again,  hunger  may  be  so 
intense  that  the  patient  is  absolutely  miserable  when  the  stomach  is 
empty,  mth  trembling  hands  and  an  impending  sense  of  fainting,  to 
be  allayed  only  by  taking  food.  Such  an  "ox  hunger,"  described  in 
the  Anabasis  as  the  complaint  of  one  of  the  generals  in  that  campaign, 
may  be  associated  with  functional  dyspepsia  or  may  be  a  symptom  of 
gastric  hypersecretion.  Then,  too,  there  are  certain  persons  who  have 
a  desire  for  food  which  is  highly  seasoned,  or  who  can  eat  only  such 
food  as  is  covered  with  the  various  sauces  like  Worcestershire  or 
catsups.  Many  people  are  satisfied  with  a  few  mouthfuls  and  after 
this  point  is  reached  have  to  be  urged  to  continue,  while  others  re- 
quire large  amounts  of  food  before  they  acquire  that  sense  of  com- 
fort and  gratification  which  goes  with  a  full  stomach  in  health.  This 
often  carries  them  to  a  point  where  more  than  the  necessary  calories 
for  the  needs  of  the  body  are  taken — a  false  sense  of  hunger,  as  it 
were — and  obesity  follows.  All  these  peculiarities  are  of  diagnostic 
importance,  for  each  is  often  associated  with  a  particular  form  of  dis- 
ease of  the  digestive  tract  and  with  no  other.  In  gastric  catarrh  due 
to  cardiac  failure  and  hepatic  cirrhosis  the  appetite  is  lacking  or  much 
impaired,  as  it  is  also  in  achylia.  In  gastric  ulcer  the  appetite  is 
maintained  or  increased,  while  most  of  the  erratic  changes  in  appetite, 
disgust  for  certain  foods,  desire  for  inedible  articles  like  slate  pencils, 
chalk,  etc.,  arise  from  gastric  neuroses.  Functional  constipation  and 
chronic  appendicitis  may  cause  impaired  appetite  apart  from  the  fear 
of  the  pain  in  the  latter  condition,  which  is  often  aroused  by  over- 
distention  of  the  stomach  with  food. 

Disturbances  of  the  Sense  of  Thirst. — Great  increase,  apart  from 
diabetes,  usually  comes  from  those  digestive  disorders  which  are  as- 
sociated wdth  frequent  vomiting  or  diarrhea.  Pyloric  stenosis,  too, 
where  large  quanities  of  fluid  are  retained  in  the  stomach,  greatly  in- 
creases the  desire  for  fluid,  and  to  the  inability  to  get  liquid  to  the 
tissues  in  this  condition  is  often  ascribed  gastric  tetany. 

Disturbances  of  Taste. — These  disturbances  are  usually  found  in 
acute  indigestions,  so-called  bilious  attacks,  in  chronic  gastric  catarrh, 
and  fermentative  and  putrefactive  processes  in  the  stomach,  as  in  an 
ulcerating  cancer.  Particularly  in  the  last  do  the  patients  complain 
of  the  taste  of  overripe — i.e.,  high  game  or  meat — while  usually  the 
complaint  is  of  a  bitter  or  sour  taste.  There  is  usually  no  complaint 
of  unusual  taste  either  in  gastric  ulcer  or  hypersecretion. 


EXAMINATION   OF   THE   PATIENT  57 

Feeling  of  Pressure  and  Fullness. — This  sensation  may  occur  in  all 
grades  of  severity  of  gastric  disorders  from  the  merest  functional 
dyspepsia  to  early  gastric  cancer.  It  may  occur  after  eating  and  dis- 
appear one  or  two  hours  after  meals,  or  may  continue  until  the  next 
meal,  or  be  present  only  when  the  stomach  is  empty  and  disappear 
for  a  time  after  eating.  Sometimes  its  severity  depends  on  the  na- 
ture or  amount  of  food,  and  again  it  seems  to  follow  no  known  law. 
In  practice  in  the  clinics  among  unintelligent  people  this  sensation 
is  always  referred  to  as  a  pain,  and  careful  questioning  must  be  em- 
ployed to  differentiate  them.  Almost  every  one  has  at  sometime  had 
a  toothache,  and  a  query  as  to  whether  the  pain  is  as  severe  as  that 
ill  brings  out  the  fact  of  the  feeling  of  fullness  or  pressure.  Some 
complain  of  it  after  the  very  first  mouthful,  and  are  relieved  by  eruc- 
tation of  gas.  Lately  we  have  noted  that  this  feeling  may  increase 
to  almost  unendurable  intensity,  extending  through  to  the  back,  and 
under  these  conditions  cholelithiasis  is  often  the  cause.  Other  than 
this,  it  has  no  diagnostic  value,  since  it  is  found  under  so  many 
conditions.  At  times  this  sensation  is  not  due  to  a  stomach  condition 
at  all,  but  to  a  distended  colon,  and  is  exaggerated  when  the  stomach 
fills  with  food  from  pressure  of  a  normally  filled  viscus  on  a  distended 
colon,  and  relief  comes  not  from  eructations,  but  from  free  passage 
of  gas  from  the  anus. 

Pain. — This  symptom,  of  all  others,  requires  the  most  careful  in- 
terpretation, because  one  patient  will  regard  any  discomfort  as  pain, 
while  another  will  deny  the  presence  of  pain  unless  it  is  severe  enough 
to  "double  him  up,"  as  he  expresses  it.  Many  describe  their  pain 
as  stabbing,  burning,  gnawing,  or  oftener  as  stomach  "cramps." 

At  first  we  must  satisfy  ourselves  that  the  pain  complained  of  is 
actually  associated  with  the  stomach,  for  patients  generally  ascribe  all 
abdominal  pains,  whether  from  gall  bladder  or  intestinal  (lead)  colic, 
epigastric  hernia  or  renal  colic,  appendicitis  or  salpingitis,  to  the 
stomach,  and  w^e  have  heard  the  pains  of  extrauterine  pregnancy  de- 
scribed by  a  patient  as  stomach  cramps;  nor  if  they  are  asked  to 
localize  the  pain  is  one  much  better  off,  for  the  whole  hand  is  used, 
and  an  area  of  the  abdomen  is  usually  covered  which  might  include 
almost  all  the  abdominal  organs.  Asking  the  patient  to  point  with 
the  index  finger  helps  some,  but  Cabot  uses  a  term  which  promises 
much — put  the  patient  in  bed  and  allow  the  pain  or  tenderness  to 
^'localize."  If,  however,  the  patient  describes  the  onset  of  the  pain 
with  the  taking  of  food,  it  may  be  generally  regarded  as  arising  from 
the  stomach,  except  in  the  instances  of  which  we  have  spoken,  where 


58  DISEASES   OF   THE   DIGESTIVE   TRACT 

taking  food,  especially  in  fairly  large  amounts,  may  arouse  the  pain 
of  cholecystitis.  This  close  connection  of  pain  with  the  ingestion 
of  food  is  especially  noticeable  in  gastric  ulcer,  and  more  emphatic 
still  is  the  fact  that  coarse  foods  bring  on  the  pain  promptly,  while 
liquid  food  may  fail  to  arouse  it.  This  is  not  only  true  of  gastric 
ulcer,  but  of  malignant  disease  of  the  intestine,  and  Stiller  recom- 
mends the  use  of  coarse  foods  with  a  large  amount  of  cellulose — like 
black  bread,  beans,  greens,  sourkrout,  etc. — where  any  doubt  exists 
by  producing  an  attack  of  pain,  and  perhaps  occult  bleeding,  to  verify, 
for  instance,  the  diagnosis  of  malignant  disease  of  the  colon.  In  case 
of  gastric  ulcer  the  pain  often  streams  toward  the  back  and  left 
shoulder  blade,  and  some  patients  even  complain  that  the  pain  in  the 
back  is  more  severe  than  that  in  front.  The  pain  of  gastric  ulcer,  too, 
is  exaggerated  by  moving  about  and  lessened  by  rest  in  bed.  Duodenal 
ulcers  also  have  much  the  same  characteristics  in  regard  to  pain,  but 
the  latter  comes  on  much  later,  three  to  six  hours  after  food,  and  is 
usually  relieved  for  a  time  after  food  is  taken.  It  must  be  conceded, 
however,  that  duodenal  ulcers  may  exist  without  any  pain,  and  pa- 
tients are  brought  into  our  relief  hospital  almost  moribund  from 
hemorrhage  from  duodenal  ulcer  who  never  had  a  symptom  severe 
enough  to  attract  their  attention. 

The  pain  in  gastric  ulcer  is  probably  due  to  the  mechanical  irrita- 
tion of  the  food,  the  corrosive  or  chemical  action  of  the  highly  acid 
gastric  juice,  and  hyperemia  about  the  ulcer.  That  the  acid  causes  an 
attack  of  pain  is  often  easily  demonstrated  by  the  readiness  with  which 
the  suffering  ceases  when  wiiite  of  egg  or  an  alkali  is  given  the  patient, 
though  this  may  also. be  true  where  the  secretion  of  an  active  gastric 
juice  persists  after  the  food  has  left  the  stomach,  the  so-called  con- 
tinuous secretion.  With  this  condition,  too,  on  account  of  the  similar- 
ity of  the  symptoms,  is  often  confounded  a  duodenal  ulcer.  Where 
a  chronic  ulcer  exists  we  may  also  have  a  cramplike  attack  of  pain 
from  the  spasm  of  the  pylorus.  Sometimes  the  pain  streams  to  the 
right  under  the  costal  border,  instead  of  to  the  left  and  back,  and 
may  then  be  mistaken  for  cholelithiasis,  but  the  pain  of  the  latter  is 
more  liable  to  occur  at  night,  and,  if  an  ordinary  meal  that  is  not  ex- 
cessive in  amount  is  taken,  less  likely  to  be  associated  with  food.  The 
pain  of  gastric  neurosis  is  characterized  by  its  erratic  nature.  The 
patient  says  "sometimes  it  occurs  and  sometimes  not."  It  may  occur 
after  excitement  or  may  be  absent,  may  be  experienced  when  food  is 
taken  or  when  the  stomach  is  empty,  so  that  it  is  always  wise  to  ask 
the  patient,  ''When  do  you  feel  better,  after  you  have  eaten  or  when 


EXAMINATIOX    OF    THE   PATIENT  59 

the  stomach  is  empty  ? ' '  This  erratic  character  of  the  pain  may  be 
found  with  nicer,  and  sometimes  we  meet  a  neurosis  where  the  pain 
is  noticed  only  after  eating.  Pain  which  at  least  the  patient  ascribes 
to  the  stomach  may  occur  in  anemic  individuals  of  the  female  sex, 
especially  at  the  menstruation,  and  gastric  pain  is  common  in  tabes 
usually  associated  with  vomiting.  In  diabetes,  pain  in  the  stomach, 
as  well  as  neuralgias  elsewhere,  is  common,  and  recently  pain  of  a 
spasmodic  nature  has  been  described  in  both  the  epigastrium  and 
abdomen  in  arteriosclerosis.  The  pain  in  the  latter  condition  has 
no  relation  to.  food,  but  is  more  often  brought  on  by  muscular  effort. 
Its  more  frequent  onset  at  night,  its  association  with  the  prone  posi- 
tion, and  its  conjunction  often  with  angina  pectoris  make  it  less  liable 
to  be  confounded  with  that  of  gastric  ulcer. 

The  cause  usually  given  for  these  attacks  of  pain  is  spasm  of  the 
smaller  arteries  of  the  gastrointestinal  tract  and  the  consequent  in- 
crease in  blood  pressure.  Very  often  the  pain  of  intercostal  neuralgia 
and  gallstone  colic  is  confounded  with  gastralgia,  and  it  is  most  diffi- 
cult sometimes  to  differentiate  the  latter  two  conditions.  Gastralgia 
may  occur,  too,  with  an  acute  appendicitis,  and  is  not  unknown  in  the 
chronic  form  of  this  difficulty.  Intestinal  colic  and  renal  colic  may 
simulate  a  gastralgia,  but  in  the  latter  case  the  pain  streams  along 
the  ureter  to  the  bladder  region,  even  to  the  vulva  in  woman  and  the 
testicle  and  penis  in  man.  Hernia  of  the  linea  alba,  of  the  femoral 
and  inguinal  canal,  and  even  a  myalgia  of  the  recti,  may  produce 
pain  in  the  epigastric  region,  but  in  the  latter  instance  Schmidt  has 
called  attention  to  the  fact  that  the  pain  is  associated  with  tenderness 
on  superficial  pressure,  which  is  not  increased  on  deep  pressure.  We 
should  never  be  content,  however,  with  the  mere  statement  of  the 
patient  as  to  the  site,  extent,  or  time  of  the  pain,  particularly,  as 
has  been  stated,  when  it  occurs  after  food  and  leads  us  to  think  of 
gastric  ulcer. 

Abnormal  Sensations  in  the  Epigastrium. — These  sensations  may 
be  confined  strictly  to  this  region,  or  may  extend  to  the  esophageal 
region.  The  sensation  of  a  lump  in  the  throat  or  of  food  sticking 
there,  of  which  patients  complain,  may  be  the  globus  hystericus  of 
hysteria,  or  it  may  be  due,  as  Boas  points  out,  to  tough  mucus  adher- 
ing to  the  pharynx  or  esophageal  walls,  giving  the  sensation  in  the 
oversusceptible  of  this  lump  or  obstacle.  It  has  been  our  personal 
observation  that,  when  only  such  a  sensation  is  complained  of,  the  tube 
passes  readily  into  the  stomach,  and,  when  real  obstruction  exists, 
regurgitation  of  food  is  the  chief  symptom.     Often  the   complaint 


60  DISEASES   OF   THE   DIGESTIVE   TRACT 

of  a  foreign  body  in  the  stomach  is  made,  and  many  weird  tales  of 
lizards  and  snakes  in  the  stomach,  acquired  by  drinking  from  springs, 
etc.,  reach  the  newspapers.  Such  a  sensation  may  be  associated  with 
a  tumor  of  the  stomach,  but  is  more  often  simply  a  modification  of 
the  feeling  of  pressure  and  distention  after  food.  In  many  instances 
these  sensations  are  purely  psychical,  for,  when  the  stomach  is  washed 
out,  nothing  is  found.  Very  often  patients  complain  of  a  feeling  of 
unusual  movements  in  the  stomach;  these  usually  occur  in  neurotics, 
and  may  be  due  to  increased  gastric  peristalsis.  Then,  again,  we  hear 
of  throbbing  of  the  stomach,  which,  being  coincident  with  the  heart 
beat,  is  probably  due  to  the  pulsations  of  the  abdominal  aorta,  and  is 
generally  associated  with  a  prolapsed  or  overdistended  stomach,  or 
sometimes  due  to  the  increased  blood  pressure  (noticeable  to  the  pa- 
tient) during  digestion.  Occasionally  we  have  instances  where  this 
feeling  of  increased  gastric  activity  is  actually  due  to  pyloric  stenosis, 
but  in  many  others  the  peristaltic  waves  are  easily  seen,  but  not  felt 
by  the  patient,  nor  do  they  manifest  themselves  as  "cramps."  iVIuch 
the  same  is  true  of  the  lower  abdomen.  Increased  intestinal  peristal- 
sis often  produces  uncomfortable  sensations  without  actual  pain,  and 
the  stabbing  sensation,  often  complained  of  by  patients  with  sluggish 
bowels  and  more  or  less  distention  under  the  right  and  left  costal 
border,  is  often  due  to  increased  activity  on  the  part  of  the  colon  and 
spasmodic  contraction  of  the  hepatic  and  splenic  flexures,  which  is 
verified  by  the  occasional  noisy  rush  of  gas  and  temporary  relief; 
these  are  the  so-called  "gas  pains,"  a  term  much  abused,  for  the 
same  condition  may  mean  an  organic  stricture,  which  is  overlooked 
by  our  easy  explanation  of  gas  pains.  Not  infrequently  we  have 
found  a  patient  with  this  complaint  who  had  a  well-marked  ascites, 
and  the  distention  which  was  considered  due  to  gas  turned  out  to 
be  fluid,  or  else  the  gas  filled  intestines  were  pushed  up  against  the 
diaphragm.  Nervous  people  especially,  when  they  are  excited,  may 
have  an  exaggerated  intestinal  peristalsis,  accompanied  by  loud  bor- 
borygmi,  without  any  distinguishable  distention  or  undue  movements 
of  the  bowels,  a  condition  often  without  discomfort,  but  very  annoy- 
ing to  the  patient  because  of  indisposition  to  associate  with  others  on 
account  of  the  noises.  Special  caution  should  be  taken  not  to  regard 
these  symptoms  as  due  to  organic  stricture,  for  they  are  often  found 
in  well-nourished  individuals. 

Heartburn  (Pyrosis). — This  is  a  sensation  of  heat  and  burning 
along  the  esophagus,  or  rather  under  the  breast  bone,  and  some- 
times in  the  pharynx,  though  patients  usually  say,  when  asked,  that 


EXAMINATION   OF   THE   PATIENT  61 

no  fluid  rises  into  the  mouth  that  can  be  tasted.  It  is  generally  as- 
sociated with  hypersecretion,  and  that  often  of  a  high  grade,  and 
should  be  differentiated  from  burning  in  the  stomach,  which  is  more 
often  a  symptom  of  fermentation  of  food,  though  it  may  be  due  to 
the  same  cause — too  great  a  concentration  of  hydrochloric  acid. 
Rarely,  in  both  cases,  acrid  fluid  does  ascend  into  the  mouth,  having 
an  extremely  sour  taste  and  giving  the  sensation  of  corroding  the 
teeth.  It  may  be  noticed,  too,  where  there  is  no  increase  in  the 
normal  acid  of  the  stomach ;  in  fact,  sometimes  the  acid  is  diminished 
or  wanting.  In  the  last  instance  it  is  probably  due  to  organic  acids. 
Some  would  have  us  understand  that  there  is  a  sensory  peculiarity  in 
some  stomachs  of  such  a  character  that,  when  the  acid  tide  reaches  a 
certain  level,  the  patient  suffers  discomfort  of  this  character  until 
the  food  leaves  the  stomach — in  other  words,  a  hypersensitiveness  to 
the  normal  acidity.  The  cause  of  this  heartburn  is  variously  stated 
to  be  the  regurgitation  of  the  acid  contents  along  the  normal  esophagus, 
which,  on  account  of  its  alkaline  secretion,  is  peculiarly  sensitive  to 
acid,  and  by  others  to  be  due  to  relaxation  of  the  cardia,  by  which  the 
gastric  contents  easily  reach  the  esophagus.  At  least  we  have  noted 
in  many  cases  of  heartburn  that  the  gastric  contents,  when  removed, 
readily  gush  up  around  the  tube  instead  of  coming  wholly  through 
it.  The  esophagus,  too,  possesses  a  much  greater  degree  of  sensibility 
than  the  stomach,  so  that  a  degree  of  acidity  which  would  cause  no 
discomfort  in  the  latter  might  produce  considerable  suffering  in  the 
former.  Then,  again,  we  have  patients,  otherwise  perfectly  well,  who 
have  this  symptom  only  after  certain  foods  like  eggs  (yolk),  coffee 
(with  cream  and  sugar),  and  fats. 

Nausea. — This  symptom  usually  precedes  vomiting,  and  may  be 
dependent  on  brain  lesions  (cerebral  anemia,  gummata,  and  tuber- 
culosis) as  well  as  gastric  lesions.  It  is  found  in  all  forms  of  gastric 
neuroses,  and  the  most  obstinate  cases  with  which  we  have  ever  had 
to  deal  were  those  where  it  arose  in  one  instance  from  eyestrain  and 
in  the  other  from  a  purely  nervous  achylia  gastrica;  hence,  from  its 
varied  etiology,  it  has  but  little  diagnostic  value.  It  usually  comes 
on,  when  of  gastric  origin,  directly  after  eating ;  in  neuroses  and  hyper- 
secretion it  occurs  when  the  stomach  is  empty,  and  can  often  be 
promptly  relieved  by  eating.  "We  find  it  naturally  in  the  early  preg- 
nant woman  and  in  the  young  girl  at  puberty,  particularly  when 
associated  with  chlorosis.  It  also  is  present  with  tape  worm.  Func- 
tional constipation  also  may  be  a  cause  of  nausea,  which  can  be  re- 
moved by  free  catharsis. 


62  DISEASES   OF   THE   DIGESTIVE   TRACT 

Difficulty  in  Swallowing. — This  condition,  while  not  really  one  of 
the  gastric  symptoms,  is  so  closely  associated  with  them  that  it  should 
be  considered  here.  Specially  low- lying  strictures  of  the  esophagus 
are  mistaken  by  the  patient,  and  also  very  often  we  are  sorry  to  say, 
by  the  profession,  for  gastric  affections.  Often  only  from  the  patient 
can  it  be  learned  that  the  food  feels  as  if  it  stuck  under  the  breast 
bone,  and  demands  a  glass  or  two  of  water  to  dislodge  it,  and  that 
fluids  are  borne  much  better  than  solid  food,  a  statement  equally  true 
of  stomach  affections,  and  the  pain,  strange  to  say,  is  always  attributed 
to  the  epigastrium.  We  have  seen  an  early  malignant  esophageal 
stricture,  34  cm.  from  the  teeth  treated  three  months  in  the  out- 
patient clinic  of  one  of  our  best  hospitals  as  a  gastric-  neurosis. 
Schuetz  calls  attention  to  a  statement,  often  made  by  the  patient, 
that  he  can  digest  fat  meat  much  better  than  lean  meat  as  suggestive 
of  stricture,  since  the  fat  meat  goes  through  much  better,  while  ordi- 
narily fat  is  less  easily  digested  in  pure  gastric  disorders.  Deglutition 
hindrances  may  exist  equally  well  from  spasm  of  the  pharynx  or 
esophagus  in  nervous  individuals  or  inflammatory  disturbances  in  both 
regions.  Both  from  paralysis  of  the  deglutitory  muscles  and  divertic- 
ula due  to  atony  we  may  have  difficulty  in  swallowing,  while  true  stric- 
ture due  to  other  causes  than  peptic  ulcer  and  malignant  disease  is 
much  less  common  in  this  country  than  in  Germany,  where  the  beer 
and  lye  are  kept  in  similar  bottles  and  often  in  the  same  cupboard. 

The  statement  of  the  patient  that  fluids  can  be  swallowed  without 
difficulty,  while  solids  give  trouble,  must  always  arouse  the  suspicion 
of  organic  stricture,  whose  nature  can  be  determined  only  by  thorough 
examination  of  the  esophagus — first  with  soft  tubes,  and  then,  if  these 
fail  to  go  through  the  narrowing,  with  solid  esophageal  sounds. 

Eructation  (Belching). — This  consists  of  voluntary  or  involun- 
tary elimination  of  gas  from  the  esophagus  or  stomach  through  the 
mouth,  which  may  consist  of  swallowed  air,  of  gases  contained  in  the 
food,  or  the  products  of  fermentation  or  putrefaction  of  food  in  the 
stomach.  The  eructations  may  either  be  tasteless,  possess  the  taste 
of  the  food  eaten,  or  have  a  sour  or  bitter  taste.  There  may  be  no 
taste,  but  the  eructations  may  possess  a  disagreeable  odor.  AYe  have 
been  obliged  to  open  our  office  windows  at  times  when  patients  suf- 
fering from  gastric  cancer  have  brought  up  gas  from  the  stomach, 
and  still  the  patient  complained  of  no  taste  but  of  the  unpleasant  odor, 
which  was  perceptible  to  him  and  exceedingly  annoying.  Fluid  con- 
tents of  the  stomach  may  be  brought  up  with  the  gas  into  the  gullet 
and  sometimes  into  the  mouth.     This  belching  may  be  noiseless  or  ex- 


EXAMINATION    OF    THE   PATIENT    .  63 

tremely  noisy,  and  sometimes  has  a  regular  rhythm  to  it.  Very  often 
the  patient  insists  on  giving  an  illustration  of  it,  and  it  has  always 
occurred  that  this  exhibition  is  of  the  noisy  variety  and  usually 
puts  the  patient  do\\'n  as  a  neurasthenic.  It  may  occur  directly  after 
the  meals,  or  some  time  after,  or  often  occurs  with  no  relation  to 
meals,  particularly  in  the  night  time ;  w^hen  it  takes  place  at  this  time, 
it  should  be  ascribed  often  to  cholecystitis.  Patients  declare  that  these 
eructations  give  relief,  and  attempt  to  provoke  them  either  by  com- 
pressing the  stomach  between  the  diaphragm  and  abdominal  walls  by 
taking  a  long  respiration,  holding  it  and  pressing  as  at  stool,  or  else  by 
consciously  or  unconsciously  swallowing  air.  This  symptom  may  be 
found  with  all  forms  of  gastric  disorders  from  a  slight  indigestion 
to  gastric  cancer.  Still,  from  some  of  the  characteristics  accompanying 
it  we  may  often  draw  certain  conclusions.  If  the  belching  is  very 
noisy  and  the  patient  attempts  to  show  how  it  is  done,  it  may  be  re- 
garded largely  as  a  nervous  affection  (eructatio  nervosa).  When 
the  eructated  gas  is  tasteless  or  has  the  taste  of  the  food,  it  is  likely 
to  be  swallowed  air,  an  accumulation  of  which  in  the  stomach — often 
from  hasty  eating — causes  the  sense  of  fullness  and  pressure  which 
is  relieved  by  the  belching.  On  the  other  hand,  as  we  may  learn 
from  the  x-ray  picture,  where  the  "stomach  bubble"  is  almost  always 
present,  from  the  drinking  of  soda  water  and  from  the  effervescing 
mixture  used  in  physical  examination  of  the  stomach,  the  presence  of 
considerable  amounts  of  gas  in  the  stomach  may  not  cause  discomfort. 
Hence  we  must  find  some  conjoint  cause  for  the  discomfort,  and  this 
is  probably  an  oversensitiveness  of  the  stomach  or  a  cramp  of  the 
same  produced  by  the  distention  of  the  gas.  In  our  oa\ti  expe- 
rience we  have  never  found  any  distress  produced  by  the  use  of 
sodium  bicarbonate  and  tartaric  acid  for  diagnostic  distention  of  the 
stomach,  but  in  Boas'  clinic  we  have  seen  so  much  distress  caused  that 
it  was  necessary  to  introduce  a  stomach  tube.  The  eructation  of  sour- 
tasting  fluid  from  the  stomach  is  usually  associated  with  pyrosis,  and 
is  due  to  the  same  cause.  Bitter  eructations  are  due  to  fermentative 
changes  in  the  gastric  contents,  when  they  often  interchange  with 
acid,  or  often  to  the  presence  of  partially  digested  protein,  w^iich  has, 
as  is  well  known,  a  bitter  taste.  The  patients,  however,  usually 
ascribe  this  taste  to  bile,  and  regard  their  livers  as  somehow  at  fault. 
Eructation  with  the  odor  of  sulphureted  hydrogen  or  rotten  eggs, 
as  it  is  often  described  by  the  patient,  as  before  stated,  is  usually  due 
to  a  malignant  growth  which  has  begun  to  break  down.  It  is  also 
probable  that  the  reflux  of  intestinal  gases  into  the  stomach  may  be 


64  DISEASES   OF   THE   DIGESTIVE   TRACT 

the  cause  of  a  bad-smelling  ructus,  as  it  is  often  assumed  by  the  laity, 
and  such  a  reversed  peristalsis  has  actually  been  demonstrated  by  the 
x-ray  examination.  Very  often  a  foul  breath  may  be  associated 
with  such  eructations;  the  more  disconnected  \Wth  the  taking  of  food 
this  eructation  may  be,  the  more  likely  it  is  to  be  of  a  nervous  char- 
acter. 

Vomiting. — This  symptom  has  about  the  same  causation  as  the 
nausea  which  has  already  been  described.  It  is  dependent  on  the  irri- 
tation of  the  vomiting  center,  which  may  be  aroused  in  many  ways. 
It  may  arise  from  the  brain  itself  when  suffering  organic  or  functional 
disease,  such  as  the  repeated  vomiting  sometimes  noticed  after  a  fall 
upon  the  head ;  or  it  may  arise  from  poisoning,  as  the  persistent  vomit- 
ing after  gas  poisoning;  or  it  may  arise  by  reflex  action  from  disease 
of  some  organ  in  the  lower  abdomen,  as  in  the  vomiting  of  acute  ap- 
pendicitis. The  vomiting,  too,  often  indicates  its  own  significance  in 
the  manner  in  which  it  occurs,  as  in  the  nervous  vomiting  of  neur- 
asthenics, in  hysterics,  or  in  meningitis,  in  that  the  act  is  not  connected 
with  the  taking  of  food  and  is  not  preceded  by  nausea  nor  pallor; 
the  act  follows,  too,  with  great  ease  and  is  not  accompanied  by  strain- 
ing. It  often  occurs  while  the  individual  is  fasting,  as  in  the  early 
morning,  is  very  erratic,  ceasing  and  recurring  without  any  known 
cause,  and  one  is  often  surprised,  after  being  told  that  practically  all 
the  food  is  thrown  up,  to  note  how  little  effect  it  has  had  on  the  phys- 
ical condition  of  the  patients,  sinc€  they  often  appear  well  nourished. 
We  must  always  be  careful,  when  the  vomiting  has  the  characteristics 
which  have  been  mentioned,  not  to  ascribe  it  to  a  functional  nervous 
disorder,  even  though  other  symptoms  are  present,  without  thorough 
examination,  for  it  sometimes  turns  out,  as  we  have  seen  it  in  at  least 
two  cases,  that  the  actual  cause  was  disease  of  the  brain,  in  one  in- 
stance being  tuberculosis  and  in  the  other  a  gumma,  which  un- 
fortunately was  not  discovered  until  the  autopsy.  Sometimes  we  note 
that  the  vomiting  is  periodical,  occurring  at  well-defined  intervals,  and 
associated  with  gastric  crises,  or  accompanied  with  pain,  as  in  tabes 
and  other  diseases  of  the  cord,  or  with  hemicrania  in  migraine ;  and  at- 
tacks of  gall  stone  and  renal  stone  colic,  accompanied  by  vomiting, 
may  often  assume  considerable  regularity  in  their  occurrence.  We 
have  also  a  form  of  periodical  vomiting  in  children,  which  was  sup- 
posed to  be  due  to  acid  intoxication  on  account  of  the  presence  of 
acetone  in  the  breath  and  urine,  but  the  probabilities  are  that  the  ace- 
tone is  the  result  of  the  persistent  vomiting  and  not  its  cause.  This 
vomiting  may  also  occur  in  young  girls  at  puberty,  often  in  con- 


EXAMINATION   OF   THE   PATIENT  65 

junction  with  the  menstruation;  or  may  be  dependent  on  change  of 
surroundings,  as  from  an  open  air  to  an  office  life ;  or  may  be  due  to 
fright,  as  after  a  boisterous  sea  voyage,  or  sometimes  to  anemia.  At 
times  no  adequate  cause  whatever  can  be  discovered,  but  the  most 
pronounced  characteristic  of  this  form  is  its  persistence,  resisting  all 
our  efforts  at  stopping  it,  its  freedom  from  pain,  and  the  beneficial  in- 
fluence of  rest  in  bed  and  liquid  food.  The  vomiting,  which  is  often 
associated  with  uterine  affections,  is  not  of  reflex  nature,  but  is  due 
to  the  effect  of  such  changes  on  the  nervous  and  psychic  state  of  the 
patient  as  may,  in  its  turn,  be  accompanied  by  vomiting,  just  as  is 
true  when  the  impaired  nervous  system  is  produced  by  any  other 
cause ;  at  least  this  is  true  of  versions  and  flexions  of  the  uterus,  whose 
correction  rarely  checks  the  vomiting.  When  vomiting  is  caused  by 
affections  of  the  generative  organs,  it  is  usually  produced  by  inflam- 
mation of  the  adnexa,  combined  with  localized  peritonitis,  and  the 
latter  is  the  cause  rather  than  the  former.  This  is  wholly  apart  from 
pregnancy,  which  is  w^ell  known  to  produce  emesis  for  a  certain  time, 
and  many  of  the  vaunted  measures  which  are  supposed  to  check  it 
are  usually  employed  at  the  period  when  it,  a  self-limited  affection,  is 
accustomed  to  cease.  Vomiting  accompanies  other  local  inflammation 
of  the  peritoneum  in  connection  with  appendicitis,  cholecystitis,  etc., 
and  has  many  of  the  characteristics  of  the  nervous  form — i.e.,  inde- 
pendence of  taking  food,  etc.  Furthermore,  when  the  patient  com- 
plains of  vomiting,  we  must  inquire  carefully  whether  food  fragments 
are  present,  for  many  have  at  times,  and  sometimes  directly  after  food 
is  taken,  an  excessive  flow  of  saliva,  which  is  often  brought  up  by  abor- 
tive efforts  at  vomiting  in  that  food  does  not  appear ;  this  is  variously 
known  by  the  laity  as  "dry  heaving"  and  water  brash.  Then,  too, 
efforts  to  clear  the  throat  in  pharyngitis  and  cough  produce  real  vomit- 
ing, as  is  noted  in  pertussis,  and  particularly  in  the  old  who  are 
suffering  from  emphysema  and  chronic  bronchitis  (winter  cough). 
We  cannot  accept  unreservedly  the  statement  of  excessive  smokers 
and  drinkers  that  the  morning  vomiting  is  a  symptom  of  gastric  af- 
fection, as  often  there  is  an  accumulation  of  tough  mucus  on  the 
walls  of  the  pharjmx,  which  sometimes  produces  nausea  and  vomit- 
ing. The  so-called  ''morning  vomiting"  of  hard  drinkers  is  more 
often  of  this  nature,  and  the  emesis  is  quite  copious,  since  it  brings 
up  the  saliva  and  mucus  which  have  been  swallowed  during  the  night. 
This  vomiting  may,  however,  contain  almost  pure  gastric  juice  in 
continuous  secretion,  or  there  may  be  fragments  of  food  where  a 
pyloric  stenosis  exists.     In  true  gastric  affections  the  vomiting  occurs 


66  DISEASES   OF    THE   DIGESTIVE   TRACT 

after  food  is  taken,  and  usually  at  a  stated  and  very  regular  interval 
after  that  act.  This  is  particularly  true  of  a  few  affections  like  ulcer 
of  the  stomach,  when  vomiting  comes  shortly  after  eating  at  the  con- 
clusion of  an  attack  of  pain,  or  it  may  occur  several  hours  afterward ; 
at  this  time,  too,  we  are  likely  to  have  the  vomiting  associated  with 
hypersecretion,  which  is  becoming  more  and  more  to  be  thought  to  be 
really  caused  by  a  chronic  ulcer  of  the  same  organ.  In  gastric  cancer 
the  vomiting  is  common,  but  it  may  be  absent  during  the  whole 
course  of  the  disease;  it  is  much  more  common  when  the  growth 
is  situated  at  the  pylorus  and  marked  stasis  is  present,  w^hen  the 
act  takes  place  not  often,  but  once  in  a  day,  yet  enormous  quantities 
are  brought  up,  apparently  without  much  of  any  effort  on,  the  part 
of  the  victim,  on  account  of  the  enormous  hypertrophy  of  the  muscular 
walls  of  the  stomach.  Earlier  in  the  disease,  however,  it  occurs  after 
almost  every  meal,  usually  preceded  by  an  attack  of  pain  and  often 
by  visible  peristaltic  waves.  Later,  when  the  growth  at  the  pylorus 
has  broken  down,  once  more  freeing  the  passage,  or  in  all  cases  when 
a  gastrojejunostomy  is  done — and  here  is  the  great  value  of  the  oper- 
ation in  this  disease  rather  than  a  hope  of  cure — the  vomiting  ceases. 
In  cancer  of  the  body  of  the  stomach,  emesis  is  usually  absent,  and  it 
may  occur  equally  as  well  from  any  other  cause  producing  narrow- 
ing of  the  pylorus  and  with  the  same  characteristics  as  in  cancer; 
in  chronic  gastritis  and  in  dilated  stomachs,  provided  there  is  little  or 
no  stasis,  the  vomiting  has  no  peculiar  characteristics. 

Regurgitation. — Regurgitation,  that  act  by  which,  without  nausea 
or  any  effort,  food  arises  by  the  mouthful  in  the  mouth,  and  is 
either  swallowed  or  spit  out,  should  not  be  mistaken  for  vomiting, 
as  it  always  is  by  the  patient,  who  states  that  she — for  I  have  found 
this  act  most  common  among  women — vomits  every  mouthful  she 
takes,  yet  looks  very  well  nourished.  This  is  found  particularly 
among  neurotics,  and  is  said  to  be  common  among  idiots.  We  have 
seen  one  well-marked  instance  in  a  sufferer  from  acromegaly,  whose 
intelligence,  though  dulled,  would  not  put  her  in  the  idiotic  class. 
Then,  again,  it  may  occur  in  rather  obese,  tightly  laced  ladies  who 
attempt  to  indulge  rather  strongly  in  the  delights  of  the  table.  Fur- 
thermore, it  is  common  in  stenosis  of  the  esophagus  as  well  as  in 
diverticula  and  dilatation  of  the  same  organ,  and  often  requires  a 
careful  examination  to  determine  whether  the  material  regurgitated 
comes  from  the  esophagus  or  the  stomach,  for  frequently  astonishingly 
large  quantities  may  come  from  an  esophageal  dilatation.  Rumination 
differs  from  regurgitation  only  in  that  the  food  brought  up  is  swal- 


EXAMINATION   OP   THE   PATIENT  67 

lowed  again  instead  of  being  ejected.  Some  patients  say  that,  as  long 
as  the  foods  taste  just  as  they  did  when  first  eaten,  they  reswallow 
them,  but,  when  the  material  tastes  sour  or  bitter,  they  spit  it  out. 
Again,  the  neurotics  and  those  mentally  deficient  form  the  group  to 
whom  this  act  is  common,  yet,  where  such  persons  are  grouped  to- 
gether, as  in  an  insane  asylum  or  home  for  feeble-minded,  imitation 
plays  a  great  part,  for  some  individuals  possess  and  others  easily  ac- 
quire the  power  to  regurgitate  at  will,  and  on  a  former  student  who 
had  this  power  many  interesting  experiments  in  digestion  were  tried. 
The  anatomical  basis  for  this  peculiarity  is  not  known,  but  it  may  be 
dilatation  of  the  lower  portion  of  the  esophagus. 

When  the  vomitus  contains  a  large  amount  of  fluid  with  food 
fragments,  unless  it  comes  immediately  after  a  copious  meal,  it  usu- 
ally indicates  a  dilated  stomach,  accompanied  and  often  caused  by  a 
narrowing  of  the  pylorus.  Large  amounts  of  fluid,  without  food  resi- 
due or  with  only  mere  traces  of  the  same,  may  occur  in  hypersecretion 
or  in  gastric  crises.  In  the  former  case  hydrochloric  acid  is  present, 
but  in  the  latter  we  have  often  found  it  absent ;  in  the  vomiting  of 
migraine  it  may  or  may  not  be  present.  Directly  after  a  meal  the 
vomitus  has  the  same  taste  as  the  food;  later  it  has  a  sour  taste,  and, 
if  hypersecretion  be  present,  it  is  often  excessively  acid.  At  a  much 
later  period  of  the  digestion  the  taste  may  be  bitter  from  fermen- 
tation, presence  of  peptones  or  often  bile,  if  the  vomiting  be  con- 
tinuous; in  putrefactive  changes  in  the  gastric  contents  (sarcinae)  the 
patient  also  complains  of  the  bitter  taste  of  the  vomitus.  The  odor 
of  the  vomitus  may  be  like  that  of  the  food,  or  sour  or  rancid  where 
there  is  fermentation,  or  even  alcoholic ;  when  putrefactive  changes 
are  going  on  in  the  stomach,  it  may  have  a  putrid  odor  like  spoiled 
meat,  or,  when  there  is  obstruction  or  paralysis  of  the  intestine,  the 
vomitus  may  have  a  fecal  odor,  due  to  the  indol  present,  and  the  act 
is  often  called  fecal  vomiting.  The  color  of  the  vomitus  depends 
largely  on  the  character  of  the  food  taken,  and  it  often  requires  a 
careful  examination  to  determine  whether  undigested  or  digested 
blood  (hematin)  may  not  be  mixed  with  it.  Red  wine,  certain  berry 
juices,  coffee,  and  chocolate  give  the  color  of  blood  to  the  vomitus,  and 
it  may  require  the  employment  of  a  chemical  test,  if  no  account  of 
what  food  was  taken  can  be  obtained,  to  determine  whether  the 
stain  is  due  to  blood.  If  such  means  are  not  at  hand,  it  is  much 
better  to  watch  the  stool  for  some  time  after  the  supposed  hematemesis, 
which  will  almost  certainly  contain  blood  in  quantities  sufficient  for 
a   chemical   test,   than   to   accept   the   hemorrhage   as   having   taken 


68  DISEASES   OF   THE   DIGESTIVE   TRACT 

place  and  make  a  diagnosis  of  ulcer.  Bile  which  has  remained  some- 
time in  the  stomach  imparts  to  it  a  dark-green  color,  sometimes 
termed  black  by  the  patient,  while  fresh  bile,  as  produced  by  violent 
efforts  at  vomiting,  gives  to  it  a  light-green  or  light-yellow  color. 
Streaks  of  blood,  when  found  in  vomitus  or  when  stated  to  be  there  by 
patients  who  are  easily  alarmed  thereby,  have  no  significance  as  indic- 
ative of  a  serious  gastric  lesion;  they  may  come  from  the  pharj^nx, 
mouth — particularly  the  gums,  which  bleed  easily  in  some  individuals 
— or  even  from  the  stomach,  when  the  vomiting  is  violent,  from  the 
rupture  of  small  blood  vessels  in  its  walls.  "When  any  considerable 
amount  of  blood  is  mixed  with  the  vomitus,  it  gives  the  latter  a  very 
characteristic  appearance,  particularly  if  the  hemorrhage  has  taken 
place  slowly  or  the  blood  has  remained  in  the  stomach  some  time ;  then 
it  has  the  color  of  chocolate  or  strong  black  coffee,  and  the  well- 
digested  minute  fragments  of  hematin  can  be  seen  floating  about  or 
settling  to  the  bottom  of  the  receptacle,  which  are  the  ' '  coffee  grounds, ' ' 
so  often  described. 

When  the  hemorrhage  is  excessive  and  vomiting  takes  place  soon 
after  it  occurs,  the  red  color  of  the  blood  may  be  retained,  and  this 
is  also  true  when  nosebleed  takes  place  during  sleep  and  the  blood 
is  swallowed ;  the  presence  of  this  in  the  stomach  often  causes  nausea, 
and  the  bright-red  blood  is  thrown  up.  The  same  is  true  of  blood 
from  the  lungs,  which  is  swallowed  and  then  brought  up.  and  it 
often  requires  a  very  careful  examination  of  the  lungs  before  this 
complication  can  be  cleared  up.  The  most  common  cause  of  gastric 
hemorrhage  is  ulcer.  One  observes  it  in  cancer  much  less  often 
because  the  latter  may  run  its  whole  course  without  the  erosion  of  a 
blood  vessel  which  will  cause  any  considerable  bleeding.  Bleeding 
may  arise,  too,  from  varicosities  of  the  vessels  of  the  stomach  or 
esophagus,  particularly  in  hepatic  cirrhosis,  or  from  the  rupture  of 
a  small  hardened  artery  of  the  stomach  in  arteriosclerosis.  We  must 
accept  with  considerable  skepticism  the  vomiting  of  blood  by  hysterics 
and  the  vicarious  substitution  of  gastric  hemorrhage  for  menstruation 
without  gastric  lesion ;  it  is  probable  that  a  concealed  ulcer  exists,  or 
that  simulation  is  practiced. 

We  have  already  spoken  of  the  presence  of  bile  in  the  vomitus 
when  violent  efforts  at  vomiting  are  made,  and  the  same  is  true  when 
vomiting  occurs  in  a  patient  fasting,  for  then  the  pylorus  is  appar- 
ently open.  In  many  cases  the  introduction  of  the  stomach  tube  into 
the  empty,  fasting  stomach  for  the  purpose  of  lavage  brings  a  certain 
amount  of  bile  through  the  pylorus,  even  when  no  violent  gagging 


EXAMINATION   OF   THE   PATIENT  69 

takes  place.  Continuous  vomiting  of  bile-stained  contents  usually  in- 
dicates a  narrowing  of  the  duodenum  just  below  the  outlet  of  the 
common  duct,  but  in  a  case  of  duodenal  kink  recently  under  our  ob- 
servation, which  was  substantiated  by  operation,  the  vomiting  usually 
occurred  at  night,  and  there  was  a  large  amount  of  bile-stained  fluid, 
with  much  mucus,  but  no  food  fragments.  In  fact,  mucus  is  present 
in  fairly  large  quantities  in  all  vomitus,  but  it  may  arise  from  that 
of  the  pharynx  and  esophagus  which  has  been  swallowed  as  well  as 
from  the  saliva,  the  secretion  of  all  of  which  is  increased  by  nausea 
and  the  act  of  vomiting.  The  gastric  mucus  itself  is  also  increased 
by  this  act,  so  that  mucus  in  vomitus  has  no  significance. 

Nature  of  the  Stool. — Disturbances  of  the  intestinal  function  are 
almost  always  an  accompaniment  of  diseases  of  the  stomach.  Gener- 
ally, constipation  is  present.  This  symptom  is  often  present,  not  on 
account  of  the  illness  itself,  but  on  account  of  change  of  diet  and  con- 
ditions of  life  necessary  in  gastric  disorders.  Sometimes,  too, 
diarrheas  are  present,  which  are  due  to  irritation  of  the  intestines  by 
the  products  of  disturbed  gastric  digestion,  or  because  of  the  in- 
creased burden  placed  on  the  intestines  by  the  insufficiently  prepared 
nutriment  which  leaves  the  stomach.  On  this  account  one  often  ob- 
serves diarrhea  in  achylia,  where  the  albumen  digestion  in  the  stomach 
suffers  most  particularly.  Such  gastrogenous  diarrhea  occurs,  since 
the  undigested  meat  remnants  furnish  an  excellent  medium  for  the 
growth  of  numerous  bacteria,  and  in  this  way  encourage  the  putre- 
faction of  the  meat. 

Flatulency. — This  symptom,  which  is  so  common  in  gastric  diseases, 
accompanied  by  meteorism  and  gaseous  distention,  is  dependent  largely 
on  the  same  causes  which  produce  the  eructation — that  is,  abnormal 
production  of  gas  by  fermentation  processes  and  by  the  swallowing  of 
air.  The  intestinal  distentions  which  are  so  common  an  accompani- 
ment of  the  gastric  distention  are  dependent  on  the  necessary  relations 
between  the  gastric  and  intestinal  disturbance,  especially  on  constipa- 
tion and  diarrhea,  which  are  so  frequently  present. 

Foul  Breath. — This  symptom  is  considered  here  because  it  is  so 
often  present  in  diseases  of  the  stomach.  It  is  mentioned  not  only  by 
patients  who  suffer  from  gastric  disease,  but  also  by  those  who  are  free 
from  any  stomach  disorder,  as  an  unpleasant  odor  from  the  stomach, 
and  always  attributed  to  this  organ.  First,  it  should  be  mentioned 
that  a  bad  breath  is  often  only  a  subjective  sensation  produced  either 
through  psychic  influence  or  oversensitiveness  of  the  sense  of  smell. 
The  real  foul  breath  is,  temporarily  at  least,  noticed  by  others ;  some- 


70  DISEASES   OF   THE   DIGESTIVE   TRACT 

times  the  patients  also  are  tormented  by  this  difficulty.  It  is  evident 
that  this  odor  may  be  produced  by  purely  local  conditions,  which  arise 
either  in  the  mouth  and  its  neighboring  parts,  produced  by  stomatitis, 
pharyngitis,  hypertrophy  of  the  tonsils,  caries  of  the  teeth,  alveolar 
abscess,  pyorrhea,  necrosis  of  the  jaw,  and  ozena.  It  may  also  be 
present  from  disease  of  the  lungs,  chronic  bronchitis,  and  bronchiec- 
tasis. A  very  common  cause  of  bad  breath,  as  is  well  known,  is  the 
lack  of  care  of  the  teeth  and  the  mouth;  a  further  cause  is  an  ex- 
tensive coating  of  the  tongue,  especially  when  it  occurs  in  connection 
with  severe  illness  and  as  a  result  of  insufficient  alimentation,  particu- 
larly where  there  is  an  insufficient  ingestion  of  solid  food.  Gastric 
disease  may  be  a  direct  cause  of  foul  breath  when  fermentative  or 
putrefactive  processes  are  taking  place  in  the  stomach.  Furthermore, 
one  often  finds  a  perceptible  bad  odor  of  the  breath  in  some  cases 
where  no  subjective  digestive  difficulties  are  present,  where  the  exami- 
nation of  the  stomach  shows  a  perfectly  normal  condition,  and  where 
none  of  the  above-mentioned  causes  are  responsible.  In  some  cases 
this  symptom  is  so  intense  that  the  odor  is  not  only  perceptible  in  the 
immediate  vicinity  of  the  patient,  but  is  also  noticeable  in  any  room 
which  the  patient  may  enter.  It  has  been  supposed  that  this  may  be 
due  to  the  entrance  of  intestinal  gases  through  the  open  pylorus  into 
the  stomach,  or  to  the  increased  absorption  of  these  gases  into  the 
blood  and  the  transference  of  the  same  to  the  expired  air.  It  is  not 
to  be  doubted  that  gases  may  make  their  way  from  the  intestines 
directly  into  the  stomach,  but  in  what  conditions  an  increased  ab- 
sorption of  intestinal  gases  may  take  place  is  uncertain.  That  con- 
stipation alone  may  play  a  part  in  this  (as  is  sometimes  supposed) 
is  not  probable,  since,  in  spite  of  the  great  frequency  of  the  former 
condition,  a  bad  breath  is  not  a  common  occurrence.  On  the  other 
hand,  one  often  observes  in  many  persons  afflicted  with  this  symptom 
that  the  stools  are  regular  and  satisfactory.  With  persons  who  suffer 
with  alternating  diarrhea  and  constipation  it  is  sometimes  noted  that 
during  the  period  of  diarrhea  the  odor  disappears,  to  return  with  the 
onset  of  constipation;  therefore,  in  the  latter  cases  mentioned  we  are 
decidedly  in  doubt  as  to  the  cause  of  the  odor. 

It  can  be  seen  from  the  foregoing  how  necessary  it  is  that  we 
should  not  confine  ourselves  to  the  examination  of  the  stomach  alone, 
but  should  investigate  the  other  organs  of  the  body,  as  well  as  the 
nervous  system,  either  before  or  in  conjunction  with  a  gastric  examina- 
tion. On  the  other  hand,  it  can  be  easily  realized  that  we  cannot  at 
all  times  investigate  so  thoroughly  the  history  of  the  patient  as  in 


EXAMINATION    OF   THE   PATIENT  71 

the  present  regimen.  It  is  sometimes  equally  important  to  allow  the 
patient  to  give  the  history  of  his  illness  in  his  own  way,  and  from 
the  story  thus  given  to  deduce  the  more  important  symptoms  and  to 
make  inquiry  regarding  each  of  these  in  turn.  When,  however,  the 
cachexia  of  the  patient  leads  us  to  suspect  malignant  disease,  sometimes 
the  discovery  of  a  tumor  in  the  abdomen  may  at  once  clear  up  the 
nature  of  the  disease,  particularly  when  it  is  confined  to  the  epigas- 
trium. An  associated  examination  of  the  urine,  too,  will  often  be  of 
great  aid  in  the  investigation  of  the  digestive  disorder  by  the  dis- 
covery, for  instance,  of  bile  pigment,  a  strong  Ehrlich  reaction,  or  the 
presence  of  sugar  due  to  pancreatic  disease.  The  importance  of  a 
very  careful  investigation  of  the  subjective  symptoms  of  the  patient  is 
particularly  necessary,  since  in  so  many  instances  of  digestive  dis- 
orders we  are  unable  to  obtain  any  tangible  objective  findings.  In 
this  very  point  lies  the  great  difficulty  in  diagnosis  of  gastric  disease  in 
contradistinction  to  those  of  other  organs.  Furthermore,  it  must  not 
be  forgotten  that  the  condition  of  hypochondria,  which  so  often  brings 
the  patient  to  the  physician  on  account  of  an  entirely  unjustifiable 
fear  of  an  incurable  gastric  disorder,  can  often  be  overcome  at  a  stroke 
by  the  assurance  that  there  is  no  organic  disease.  This  is  a  much 
better  course  to  pursue  than  to  put  too  much  stress  in  conversation 
with  a  patient  on  moderate  atony,  dilatation,  ptosis,  etc.,  which  often 
converts  a  mild  neurasthenic  to  an  exaggerated  sufferer  from  conscious 
gastric  disease. 


CHAPTER  IV 

PHYSICAL  METHODS  OF  EXAMINATION  OF  THE  DIGES- 
TIVE TRACT 

INSPECTION. 

We  must  first  note  the  condition  of  nutrition  of  the  patient,  taking 
carefully  into  account  the  length  of  the  illness.  Rapid  loss  of  flesh 
usually  means  a  severe  sickness,  while  the  maintenance  of  a  good 
condition,  in  spite  of  continued  illness,  means  a  mild  disease.  Next 
we  must  note  the  color  of  the  skin ;  pallor  of  the  skin  or  mucous  mem- 
brane; cyanosis,  with  livid  lips;  the  lemon  tinge  of  cachexia;  icteric 
and  subicteric  coloration,  especially  of  the  scleras;  all  have  their  par- 
ticular significance,  which  will  be  brought  out  later  in  the  description 
of  the  examination. 

Mouth. — We  should  note  carefully  the  presence  or  absence  of  the 
teeth  or  caries  of  the  teeth,  and  the  condition  of  the  tongue  and 
phary^nx.  On  account  of  the  importance  of  mastication,  special  at- 
tention should  be  given  to  the  teeth,  for  improper  chewing  of  food 
produces  disturbance  of  digestion,  causes  disordered  functions  of 
the  stomach,  and  may  lead  to  organic  changes  in  the  latter.  Achylia 
is  often  noted  in  connection  with  faulty  teeth.  Furthermore,  through 
lack  of  cleanliness  of  the  teeth  and  decaying  teeth  a  multitude  of  lower 
organisms  enter  the  stomach,  and  by  action  on  the  food  produce 
deleterious  substances,  which  give  rise  to  serious  disturbances,  and 
hence  decaying  teeth  may  be  the  cause  of  gastric  disorders.  It  has 
already  been  noted  that  chronic  pharyngitis  may  produce  the  morn- 
ing vomiting,  and  therefore  a  careful  inspection  of  the  pharynx  is  al- 
ways necessary.  The  tongue  has  long  been  supposed  to  be  the  mirror 
of  the  stomach,  and  from  its  condition  we  have  sought  to  learn  the 
state  of  the  latter  organ.  With  a  heavily  coated  tongue,  appetite  is 
usually  wanting,  and  this  is  especially  true  when  the  forward  part 
of  the  tongue  is  involved,  while,  when  confined  to  the  rear  part  (as  is 
often  found  in  heavy  smokers  and  drinkers),  it  has  no  significance. 
Many  patients  often  preserve  an  excellent  appetite,  although  the  sense 
of  taste  may  be  impaired,  and  hence  both  portions  of  the  tongue  should 
be  carefully  inspected.     It  is  a   well-known  fact  that,   apart   from 

72 


PHYSICALi   METHODS  OP   EXAMINATION   OF   THE   DIGESTIVE   TRACT       73 

gastric  disorders,  the  tongue  is  coated  in  all  acute  and  chronic  disease, 
especially  when  associated  with  fever.  The  coating  may  also  be  due 
to  an  exclusive  liquid  diet,  since  through  mastication  of  solid  food 
the  tongue  is  constantly  being  cleaned.  As  far  as  gastric  diseases  are 
concerned,  the  tongue  is  found  heavily  coated  in  all  severe  acute  affec- 
tions of  the  stomach — in  chronic  gastritis  as  well  as  in  stasis  with 
fermentation,  and  in  cancer.  The  coating  is  usually  absent  in  hyper- 
secretion and  ulcer,  when  a  peculiarly  bright-red  tongue  is  often  found. 
In  gastric  neurosis  the  character  of  the  tongue  so  varies  that  little  can 
be  learned  from  it.  As  the  disease  vanishes,  the  coating  usually  grows 
less.  Another  particularly  valuable  thing  in  the  inspection  of  the 
tongue  is  that  the  presence  of  a  heavy  coating  excludes  simulation  of 
stomach  disorder  on  the  part  of  the  patient.  The  tongue's  coating  is 
made  up  of  desquamated  epithelium  and  detritus,  leucocytes,  molds, 
and  food  remnants. 

Anatomical  Configuration  of  the  Body. — An  inspection  of  the  gen- 
eral build  of  the  patient  is  of  great  importance,  since  at  a  glance  we 
may  detect  the  so-called  "habitus  enteroptieus, "  which  is  usually 
associated  with  displaced  abdominal  organs  and  disturbance  of  diges- 
tion. This  condition  has  been  described  by  Stiller,  who  first  called 
attention  to  it,  in  the  following  description :  "  It  is  usually  found  in 
the  younger  members  of  both  sexes,  with  preference  for  the  feminine. 
The  nutrition  is  poor,  the  muscles  undeveloped,  the  bones  small,  and 
the  skin  thin  and  pale;  the  clavicles  and  shoulder  blades  are  very 
prominent,  springing  from  a  narrow  chest,  whose  upper  and  lower 
apertures  are  diminished,  and  the  epigastric  angle  is  extremely  acute ; 
the  tenth  rib,  on  account  of  a  defect  of  its  cartilage,  is  shortened,  and 
from  lack  of  tone  of  its  intercostal  ligament  is  movable ;  the  abdomen 
is  flat,  narrow,  and  its  lower  portion  protrudes;  the  stomach  is  pro- 
lapsed, atonic,  and  the  right  kidney  usually  movable."  This  con- 
dition, according  to  the  author,  is  congenital  and  often  inherited.  It 
manifests  itself  in  the  digestive  apparatus  in  the  form  of  enteroptosis, 
atony,  and  nervous  disorders.  It  is  often  associated  with  chlorosis, 
tuberculosis,  gastric  ulcer,  and  orthostatic  albuminuria.  Such  a  con- 
dition as  this  we  see  often,  but  we  also  see  many  of  these  symptoms 
apart  from  this  complex,  and  hence  not  dependent  on  heredity.  On 
the  contrary,  many  persons  with  this  habitus  may  have  good  diges- 
tion, so  that  its  value  as  a  diagnostic  criterion  has  lost  something  in 
the  estimation  of  physicians. 

Abdomen. — For  a  satisfactory  examination,  the  patient  should  lie 
comfortably  in  a  horizontal  position.    Where  prolapse  of  the  stomach 


74  DISEASES   OF   THE   DIGESTIVE   TRACT 

is  suspected,  an  examination  in  the  erect  position  is  also  of  great 
aid.  The  abdomen  should  be  looked  at  from  the  front  and  also  from 
the  side,  with  the  light  striking  the  patient  preferably  from  the  feet. 
The  patient  should  breathe  at  first  superficially,  then  deeper  on  re- 
quest. We  should  note  carefully  striations,  scars  from  operations, 
varicose  veins  due  to  obstruction  of  the  portal  circulation,  and  the 
edema  of  the  abdominal  walls.  In  the  meantime  the  normal  condi- 
tions are  always  to  be  borne  in  mind.  In  thin  people  the  abdomen 
seen  from  the  side  extends  but  little,  or  not  at  all  forward.  The  side 
lines  seen  from  the  front  curve  out  slightly  from  the  costal  border  to 
the  pelvic  ilia  in  man  and  considerably  in  woman,  forming  concavities 
in  the  latter.  The  recti  can  be  seen  to  advance  in  the  muscularly  de- 
veloped when  asked  to  rise  to  a  sitting  position.  On  coughing,  all 
muscles  contract;  by  inspiration  the  abdominal  arch  increases  and 
muscular  contours  vanish ;  by  expiration  the  abdomen  flattens  out  and 
muscular  contours  appear  once  more.  In  the  obese  all  these  distinc- 
tive features  vanish.  A  layer  of  fat  often  reaching  10  cm.  prevents 
even  the  costal  borders  from  being  seen ;  a  cough  causes  only  a  general 
shaking  of  the  abdominal  walls.  The  tension  of  the  abdominal  walls 
is  dependent  on  the  fullness  of  the  digestive  canal  or  peritoneal  cavity ; 
as  this  fills,  the  walls  relax.  This  is  of  valuable  importance  for  palpa- 
tion, since  by  reflex  action  the  tension  of  the  walls  relaxes  on  full  in- 
spiration and  sublying  growths  or  organs  can  be  more  easily  felt. 
The  same  conditions  prevail  where  there  is  irritation  of  the  digestive 
tract  or  peritoneal  cavity,  as  local  or  general  peritonitis.  Then  a  lack 
of  coordination  between  the  tension  of  the  walls  and  contents  of  the 
peritoneal  cavity  exists,  and  the  diaphragm  is  forced  upward,  causing 
shortness  of  breath  and  labored  breathing.  Uniform  enlargement  or 
protrusion  of  the  abdomen  first  attracts  our  attention.  This  may  be 
due  to  the  fat  easily  detected  by  palpation  or  to  ascitic  fluid,  which 
may  be  detected  by  percussion  in  different  positions  of  the  body,  and 
often  by  dilated  veins  upon  the  surface  of  the  abdomen.  Uniform 
enlargement  is  also  often  due  to  meteorism,  caused  by  undue  disten- 
tion by  gas,  which  often  partially  obscures  the  dullness  of  the  liver. 
This  is  particularly  true  when  the  whole  small  intestine  is  distended. 
We  may  also  have  a  peritoneal  meteorism,  which  differs  from  the  in- 
testinal by  presenting  a  perfectly  equal  and  even  enlargement  over 
the  entire  abdomen,  with  a  like  tympanitic  note  and  complete  loss  of 
liver  dullness,  which  is  rare  in  intestinal  meteorism,  except  where 
paralysis  of  the  tract  is  present.  Apart  from  intestinal  paralysis,  we 
may  have  an  almost  regular  protrusion  where  there  is  stenosis  at  the 


PHYSICAL   METHODS  OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT       75 

colon  flexures,  sigmoid  or  rectum,  leading  to  an  insufficient  ileocecal 
valve  and  general  circulatory  stasis,  preventing  the  absorption  of  the 
gas,  as  in  regurgitative  heart  disease,  emphysema,  cirrhosis,  and  hys- 
teria. A  partial  enlargement  or  protrusion  of  a  part  of  the  abdomen 
may  be  due  to  the  enlargement  of  an  organ — for  instance,  the  liver, 
spleen,  etc. — or  to  a  partial  meteorism  from  stenosis  of  a  part  of  the 
tract.  This  is  not  necessarily  present  in  stenosis  when  sudden  and 
acute,  and,  if  present,  is  often  obliterated  by  the  reflex  tension  of  the 
abdominal  walls  due  to  the  peritoneal  involvement.  If  the  stomach  is 
distended  \\dth  gas  from  pyloric  stenosis,  the  epigastric  region  pro- 
trudes, or,  if  the  stomach  is  prolapsed  as  well  as  dilated,  it  may  flU 
the  whole  left  portion  of  the  abdomen  as  well  as  the  middle.  Here 
there  is  presented  a  marked  contrast  between  the  concave  epigastrium 
and  the  protrusion  of  the  middle  and  left  half  of  the  abdomen,  with 
the  flattened  right  half.  We  can  demonstrate  that  the  enlarged  por- 
tion of  the  abdomen  is  stomach  by  succussion  sounds  and  view  of  the 
contour  of  the  stomach,  or  the  latter  may  be  made  more  prominent 
by  an  effervescent  mixture.  Furthermore,  a  common  cause  of  small 
protuberances  is  epigastric  hernia,  which  appears  as  a  diffuse  or 
sharply  defined  protuberance  in  the  median  line,  which  may  be  single 
or  multiple.  The  favorite  site  is  above  the  navel — sometimes  halfway 
between  the  latter  and  the  tip  of  the  xiphoid.  The  larger  ones  are 
readily  seen,  but  the  smaller  ones  require  an  especially  good  light  and 
a  view  from  the  side.  People  often  confuse  them  with  lipomata  or 
localized  masses  of  fat;  the  former  protrude  more  by  coughing  or 
straining  than  the  latter.  Keal  umbilical  hernia  may  appear  at  the 
navel,  or  at  this  point  there  may  be  metastasis  from  other  malignant 
growths  in  the  peritoneal  cavity.  These  have  been  observed  by  the 
author  as  a  concomitant  of  primary  cancer  of  the  right  ovary,  associ- 
ated also  with  secondary  malignant  disease  of  the  great  omentum. 
"When  the  stenosis  is  situated  at  the  sigmoid,  the  whole  distention  is  in 
a  transverse  direction  and  in  the  right  flank.  When  the  obstruction 
is  at  the  ileocecal  valve,  the  meteorism  causes  a  large  distention  of  the 
middle  area  of  the  abdomen.  When,  however,  embolism  of  the  mesen- 
teric artery  takes  place,  as  described  in  Chapter  I,  what  is  equivalent 
to  a  constriction  appears  above  and  below.  We  have  a  short  length 
of  distended  gut,  which  is  extremely  tympanitic.  This  develops  very 
rapidly,  so  that  distention  above  the  first  constriction  may  not  occur. 
In  strangulated  hernia  a  distention  of  the  gut  is  visible  through  the 
abdominal  walls.  In  this  case  the  diagnosis  is  not  difficult,  especially 
when  the  enlargement  appears  above  the  usual  orifices — viz.,  the  navel, 


76 


DISEASES   OF   THE   DIGESTIVE   TRACT 


linea  alba,  inguinal  and  femoral  canal.  Sometimes  localized  abdomi- 
nal enlargements  may  arise  from  intestinal  paresis  in  hysterical  fe- 
males, or  perhaps  from  a  spasm  of  a  group  of  abdominal  muscles. 


Fig.  9. — Stenosis  in  the  vicinity  of  the  splenic  flexure.      (Nothnagel.) 

This  forms  often  the  so-called  "phantom  tumor,"  and  may  be  cleared 
up  by  relaxation  of  the  muscles  when  the  patient  is  asked  to  cough 
or  to  rise  from  a  prone  position,  both  these  actions  releasing  the 
spasm  of  the  muscles.     Localized  protrusions  may  be  produced  by 


PHYSICAL   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE  TRACT       77 


tumors  of  the  intestinal  canal  itself,  but  by  inspection  alone  such 
growths  cannot  be  distinguished  from  gaseous  distentions,  although 
their  character  may  often  be  suspected  from  their  irregular  outline, 


Yig.   10. — Stenosis  of  the  lower  ileum  from  peritoneal  adhesion.      (Notbnagel.) 

their  motion  with  deep  inspiration,  and  their  special  location,  as  at 
the  cecum,  or,  as  the  author  has  seen,  one  in  the  descending  colon,  just 
above  the  iliac  crest,  which  was  malignant,  and  one  of  the  sigmoid. 


78  DISEASES   OF    THE   DIGESTIVE   TRACT 

which  was  tubercular.  As  the  diagnosis  of  abdominal  tumors  is  one 
of  the  most  difficult  tasks  which  the  physician  has  before  him,  the  eye 
must  be  especially  trained  to  notice  the  slightest  unevenness  in  the 
contour  of  the  abdominal  level,  since  in  this  way  attention  may  be 
attracted  to  pathological  processes  which  otherwise  might  escape  his 
attention.  The  diminution  of  the  abdomen,  which  may  display  itself 
by  flatness,  prominence  of  the  costal  borders,  with  a  rapid  fall  to  the 
level  of  the  navel,  the  so-called  "canoe-shaped"  abdomen,  due  to  great 
emaciation,  to  cancer  of  the  esophagus,  or  to  tubercular  meningitis, 
sometimes  occurs.  Under  favorable  conditions^that  is,  in  spare  per- 
sons with  lax  abdominal  walls — one  can  see  the  lower  border  of  the 
stomach  when  filled.  With  a  moderate  degree  of  prolapse,  this  is 
much  easier,  and  often  both  borders  (upper  and  lower)  may  be  seen. 
When  the  stomach  is  dilated  and  the  muscles  hypertrophied,  the 
stomach  often  stands  out  from  the  abdominal  walls  in  its  whole  con- 
tour, like  a  molded  raised  figure ;  peristaltic  waves  can  also  be  seen 
moving  quickly  from  the  patient's  left  to  right  side.  These  are  very 
much  intensified  and  exaggerated  when  stenosis  of  the  pylorus  ex- 
ists. Very  rarely  in  extremely  nervous  people  we  see  the  same  thing, 
but  ordinarily  this  increased  peristalsis  means  a  stenotic  pylorus. 
Occasionally  there  may  be  seen  an  intermittent  spasmodic  tumor  in 
the  region  of  the  antrum,  the  spasm  of  the  pylorus,  when  cancer  or 
ulcer  is  present.  When  the  stenosis  is  marked  and  the  muscular  tone 
of  the  stomach  normal  or  increased,  contraction  of  the  entire  stomach 
below  the  costal  borders  (gastric  rigidity)  can  be  seen,  which  relaxes 
and  alternates  with  the  peristaltic  waves.  This  can  often  be  aroused 
by  friction  or  dropping  cold  water  from  a  height  upon  the  epigastrium. 
Ordinarily,  the  peristaltic  motions  of  the  intestines  are  not  seen. 
When,  however,  the  abdominal  wall  is  very  thin,  or  diastasis — separa- 
tion of  the  recti — allows  the  bowels  to  come  in  close  contact  with 
the  skin,  as  in  women  who  have  borne  many  children,  peristaltic  action 
during  digestion  becomes  perceptible.  This  is  confined  to  the  small 
intestine,  and  is  found  in  the  middle  of  the  abdomen.  Only  short  por- 
tions of  the  gut  appear,  are  continually  changing,  and  are  never  hard 
or  rigid.  Nothnagel  compares  their  appearance  to  potatoes  in  a  sack. 
In  nervous  people  intestinal  movements,  accompanied  by  loud  noises, 
are  visible.  Pathological  intestinal  movements  can  be  distinguished 
from  the  former  by  the  fact  that  they  can  be  seen  through  the  normal 
abdominal  walls,  and  even  when  the  individual  is  very  fat.  They, 
like  stagnation  meteorism,  when  long  continued  and  persistent,  mean 
a  narrowing  at  some  point  in  the  intestinal  tract  and  hypertrophy  of 


PHYSICAL   METHODS   OF   EXAMINATION   OF    THE   DIGESTIVE   TRACT       79 

the  irmscles  above  this  point.  In  acute  strangulation,  they  can  be  seen 
only  occasionally,  and  never  with  the  distinctness  of  chronic  stenosis. 
Pathological  peristalsis  is  not  continuous,  but  periodic,  for  the  muscles 
soon  tire  after  a  time.  Here,  again,  friction  or  dropping  cold  water 
from  a  distance  upon  the  abdominal  wall  may  start  them  up.  Ac- 
companying these,  one  often  sees  a  whole  section — not  short  stretches, 
as  in  physiological  peristalsis — raise  itself  above  the  level  of  the  ab- 


Fig.  11. — Normal  intestinal  peristalsis.      (Nothnagel.) 

dominal  wall  and  remain  hard  and  rigid  w^hile  a  peristaltic  wave 
passes  through  it — i.e.,  rigidity.  This  appearance  is  very  much  like 
a  garden  hose  when  water  is  first  let  through  it.  After  a  short  time 
the  rigid  portion  relaxes  and  sinks,  with  a  loud  gurgling  tone  as  gas 
and  fluid  pass  through  the  narrowed  portion.  This  repeats  itself 
again  in  the  same  or  neighboring  sections  until  the  muscles  of  the  in- 
testine are  exhausted.  In  distinction  from  the  physiological  peri- 
stalsis, this  consists  of  rigidity  and  peristalsis  of  the  entire  section  of 


80  DISEASES  OF   THE  DIGESTIVE   TRACT 

the  gut.  This  rigidity  usually  occurs  only  in  such  portions  as  are 
distended  with  gas  from  stagnation,  since  it  is  a  prerequisite  that 
such  inflation  should  be  visible  through  the  abdominal  wall.  Such  an 
observation,  no  matter  how  long  delayed,  often  clears  up  the  diagnosis 
at  a  glance,  and  the  author's  revered  teacher,  Professor  Oser,  of 
Vienna,  used  to  say  that  he  had  watched  hours  for  such  a  phenomenon 
in  a  patient.  With  the  intestine  empty,  similar  contractions  can  be 
seen  in  lead  colic  and  cerebrospinal  meningitis,  but  in  these  cases  the 
abdomen  is  concave,  and  they  are  not  confined  to  any  particular 
section  of  the  bowel,  but  traverse  its  entire  length. 

PALPATION. 

Sensation. — We  may  first  employ  palpation  as  a  method  of  examina- 
tion to  test  the  sensation — that  is,  to  learn  whether  a  spontaneous 
painful  sensation  or  a  tenderness  to  pressure  is  over  the  stomach,  or 
any  portion  of  the  intestinal  tract,  or  elsewhere,  as  over  the  gall- 
bladder, kidney,  etc.  Almost  every  internist  has  his  own  method  of 
the  use  of  his  hands  and  fingers  for  palpation.  The  author's  own 
preference  is  for  the  use  of  the  tips  of  all  four  fingers,  slightly  flexed, 
of  the  right  or  left  hand  indiscriminately,  according  to  the  position 
of  the  patient,  although  the  author  prefers  to  examine  standing  at  the 
patient's  right,  with,  back  to  his  head.  It  goes  without  saying  that 
the  person  examined  must  lie  on  his  back,  with  the  knees  slightly 
drawn  up.  When  general  tenderness  is  found  in  any  locality,  then 
the  tip  of  the  forefinger  may  be  used  for  circumscribing  this,  or  a 
percussion  hammer  may  be  employed  for  the  same  purpose,  a  sharp 
blow  restricting  the  area  more  closely  than  the  finger.  It  is  not,  how- 
ever, so  much  the  method  as  the  thoroughness  of  examination  of  all 
localities — epigastrium  to  the  navel,  the  right  and  left  hypochon- 
drium,  the  region  around  the  navel,  and  the  right  and  left  iliac  fossa. 
Both  deep  and  superficial  pressure  should  be  employed.  Schmidt  has 
called  attention  to  the  fact  that  superficial  tenderness  may  be  caused 
by  myalgias  of  the  abdominal  muscles,  which  will  be  discussed  later 
more  fully.  The  patient  should  breathe  both  superficially  and  deeply 
during  the  search  for  tender  spots.  If,  in  spite  of  protestations  of 
painful  sensations,  no  tender  points  can  be  found,  and  incidentally 
more  attention  be  paid  to  facial  changes  expressing  pain  than  to  loud 
exclamations  of  the  hurts  of  pressure,  we  must  rely  on  the  patient's 
history  for  the  source  of  pain,  or  put  him  dowTi  as  an  exaggerator  of 
doleful  sensations.     If  a  painful  spot  or  region  is  found,  it  is  our  duty 


PHYSICAL   METHODS   OP    EXAMINATION   OF    THE   DIGESTIVE   TRACT        81 

to  try  to  determine  whether  it  is  due  to  hyperesthesia  of  the  skin  of 
the  abdominal  walls  or  of  a  deep-lying  organ,  or  both.  Occasionally  a 
dermal  hyperesthesia  may  arise  from  disease  of  the  abdominal  organs. 
Extreme  tenderness  of  the  skin  can  be  demonstrated  by  raising  a  fold 
of  the  skin  and  pinching  it  lightly.  This  close  relation  between  dermal 
hyperesthesia  and  disease  of  the  abdominal  organs  has  often  been 
maintained,  but  for  all  practical  purposes  marked  sensitiveness  of 
the  skin,  which  is  not  particularly  circumscribed,  means  a  neurosis 
and  not  a  disease  of  the  organs  below.  It  often  happens  that  no  part 
of  the  surface  of  the  abdomen  can  be  touched  without  expressions  of 
pain  on  the  part  of  the  patient,  while,  if  attention  be  distracted,  deep 
pressure  produces  no  outcry.  It  is  one  of  the  greatest  faults  of  phys- 
ical examination  to  continue  asking  the  patient,  while  palpating  a 
certain  part,  whether  it  hurts,  because,  his  attention  being  drawn  to 
that  fact,  if  he  desires  to  impress  the  physician  with  the  severity  of 
his  case,  every  pressure  is  declared  to  be  painful.  Again,  w^e  must 
call  attention  to  the  frequency  with  which  the  recti  are  painful  to 
pressure,  as  described  by  Schmidt,  simulating  tenderness  over  an 
organ.  The  restriction  of  tenderness  to  these  muscles  can  often  be 
assured  by  grasping  them  between  the  fingers  without  exerting  pres- 
sure on  the  parts  underneath ;  when  they  are  touched  brusquely,  pain 
is  produced,  but  by  trying  pressure  gradually  we  may  exercise  con- 
siderable force  witTiout  causing  discomfort.  We  may  also  by  careful 
palpation  detect  an  epigastric  hernia,  invisible  to  the  eye,  which  may 
be  the  cause  of  pain  in  the  stomach  region.  "When  pain  is  elicited  by 
pressure,  and  we  are  assured  it  is  not  superficial,  we  must  endeavor  to 
determine  whether  it  rises  from  the  stomach,  gallbladder,  or  kidney, 
as  the  pyloric  portion  of  the  first  lies  in  close  juxtaposition  with  the 
latter  two.  When  the  patient  speaks  of  spontaneous  pain  in  the  epi- 
gastrium, particular  attention  must  be  paid  to  palpating  the  region  of 
the  appendix  and,  in  women,  of  the  uterus  and  adnexa,  for  disease  of 
these  organs  often  manifests  itself  by  pain  in  the  stomach  region. 
]\Iost  commonly,  pain  on  pressure  is  elicited  in  the  epigastric  triangle, 
bounded  by  a  horizontal  line  connecting  the  cartilages  of  the  ninth 
ribs  and  the  costal  borders  from  this  to  the  end  of  the  sternum.  At 
the  middle  of  this  base,  or  a  little  to  the  right  of  it,  is  the  "epigastric 
pressure  point,"  which  corresponds  to  the  celiac  ganglion. 

Although  the  epigastric  pressure  point  lies  usually  in  the  region  of 
the  stomach,  even  in  ulcer  of  that  organ  it  may  He  outside  its  borders, 
as  demonstrated  by  the  radiograph.  In  such  case  it  has  been  demon- 
strated that  by  change  of  position  of  the  stomach,  by  full  inspiration, 


82 


DISEASES   OF   THE   DIGESTIVE   TRACT 


etc.,  the  point  does  not  change  its  site,  and  hence  does  not  properly 
belong  to  the  stomach;  in  fact,  recent  investigations  have  shown 
that  in  ulcer  and  neurosis  the  point  lies  outside  of  the  stomach,  while 
in  other  diseases,  like  cancer  and  perigastric  adhesions,  it  belongs  to 
it.  We  have  all  noted  at  times  a  tenderness,  or  hyperesthesia,  extend- 
ing downward  from  the  epigastrium  to  the  navel,  along  the  course 
of  the  abdominal  aorta.  This  generally  means  a  neuralgia  of  the 
nerve  plexus  surrounding  the  aorta,  but  at  the  same  time  we  must 
recognize  that  it  may  be  due  to  disease  of  the  stomach,  particularly 
chronic  ulcer,  or  some  other  abdominal  organ.     It  demands  a  most 


Fig.  12. — Epigastric  pressure  point. 

careful  examination  to  differentiate  a  neurosis  of  the  celiac  plexus 
from  this  condition,  and  often  only  a  long  observation  of  the  patient 
will  clear  up  the  problem.  Many  a  so-called  cure  of  chronic  ulcer 
based  on  this  tenderness  has  really  been  a  recovery  from  a  neuralgia 
of  the  sympathetic  plexus  arising  from  a  general  neurosis.  At- 
tention must  also  be  called  to  tenderness  over  McBurney's  point — 
that  is,  a  point  where  a  line  from  the  right  anterior  superior  spinous 
process  of  the  right  ilium  to  the  navel  cuts  the  outer  border  of  the 
right  rectus  muscle  (a  little  outside  of  the  middle  of  this  line).  This 
tender  spot  is  generally  regarded  to  be  significant  of  inflammation 


PHYSICAL   METHODS   OF   EXAMINATION   OF    THE   DIGESTIVE   TRACT       83 

of  the  appendix,  but,  as  the  latter  often  changes  its  position,  the 
tender  spot  associated  with  its  inflammation  is  not  always  here;  fur- 
thermore, tenderness  at  this  point  may  accompany  disease  of  the 
ureter,  or  Fallopian  tube  on  that  side,  or  colitis.  The  actual  source 
of  tenderness  at  this  point,  as  stated  before,  is  a  nerve  plexus  lying 
upon  the  psoas  muscle,  which  is  irritated  by  all  these  diseases  of 
neighboring  organs,  and  therefore  it  is  very  unwise  to  make  a  diag- 
nosis of  inflamed  appendix  on  tenderness  alone  at  this  point.  Some- 
times the  tenderness  will  disappear  on  bimanual  examination,  with 
one  finger  in  the  rectum,  which  rules  out  the  appendix,  since,  if 
sensitive,  such  an  examination  would  increase  it.  If  the  appendix  it- 
self can  be  felt  (which  rarely  happens)  and  is  found  tender,  it  clears 
up  the  diagnosis  at  once ;  raising  the  extended  right  leg  helps  palpation 
of  this  region  considerably.  Percussion,  too,  as  stated,  may  be  called 
to  our  aid  to  verify  and  localize  tenderness.  When,  with  fully  re- 
laxed abdominal  walls,  the  epigastrium  be  tapped  lightly  with  a  per- 
cussion hammer,  the  most  sensitive  patient  makes  no  complaint  if 
the  stomach  and  adjacent  organs  are  free  from  disease.  When,  how- 
ever, a  gastric  ulcer  exists,  which  may  be  chronic  and  of  long  duration, 
a  point  is  reached  where  the  lightest  blow  causes  pain,  which  lasts 
for  some  time  after.  Now,  percussing  outward  in  radial  lines,  a 
marked  area  of  tenderness  is  found,  with  the  first  point  as  its  center, 
and  outside  of  this  area  no  discomfort  is  experienced.  These  blows 
are  supposed  to  shake  the  ulcer  surface,  whether  directly  under  the 
blow,  to  the  right,  or  even  on  the  posterior  surface  of  the  stomach. 
Mendel  believes  that  percussion  is  particularly  valuable  in  detecting 
an  ulcer  of  that  portion  of  the  stomach  which  does  not  lie  against 
the  abdominal  walls.  In  the  author's  experience  the  percussion  has 
a  value  in  excluding  ulcer  where  there  is  an  undefined  epigastric 
tenderness  of  pressure  by  the  fingers,  but  the  hammer  fails  to  elicit  a 
painful  sensation.  Schmidt  calls  attention  to  the  variability  of  this 
painful  spot  produced  by  percussion,  which  he  regards  as  dependent 
on  the  degree  of  distention  of  the  stomach.  Percussion  over  the  tip 
of  one  finger,  where  a  hammer  is  not  at  hand,  may  be  used  for  the 
demarcation  of  the  area  of  tenderness.  This  percussion  tenderness  is 
said  to  differentiate  between  hyperesthesia  and  true  gastric  disease, 
and,  if  the  point  of  greatest  tenderness  be  determined  by  increasing 
the  blows,  then  the  spot  marks  the  site  of  an  ulcer  or  a  cancer,  even 
when  the  latter  cannot  be  palpated.  There  are  various  other  pressure 
points  in  the  abdomen,  of  which  mention  has  been  made  in  Chapter  I. 
When  tenderness  is  found  at  any  of  these  points,  it  is  sometimes  most 


84 


DISEASES  OF   THE  DIGESTIVE   TRACT 


difficult  to  distinguish  between  a  hypersensitiveness  through  neurosis 
and  hyperesthesia  by  reflex  action  from  a  diseased  organ.  The  best 
way  is  to  try  each  point  in  turn — epigastric,  McBurney  's,  mesentericus 
superior  (navel)  and  inferior  (point  corresponding  to  McBurney 's 
in  the  left  iliac  fossa)  ;  if  all,  or  the  majority,  of  these  points  are 
tender,  we  may  exclude  organic  disease.  Besides  all  these,  there  are 
tender  spots  in  the  back,  under  certain  conditions,  to  which  Boas  has 
called  attention.  For  instance,  in  gastric  ulcer  there  is  one  just  to 
the  left  of  the  spinal  column  and  just  below  the  twelfth  rib  at  its 
attachment  to  the  vertebra ;  sometimes  this  is  a  little  higher  and  some- 


c;:v^ 


Fig.  13. — Dorsal  pressure  point  in  gastric  ulcer,  indicated  at  a. 

times  lower,  and  is  not  due  to  hyperesthesia,  for  the  tenderness  does 
not  appear  except  on  deep  pressure.  On  the  other  hand,  the  tender 
area  due  to  cholelithiasis  lies  on  the  other  side  of  the  spinal  column, 
extending  upward  from  the  twelfth  rib  at  its  spinal  attachment  three 
fingers'  breadth  and  an  indefinite  distance  to  the  right. 

In  gastric  neurosis,  while  the  back  may  be  tender,  there  is  no  regu- 
larity in  the  location  of  the  tender  spots.  Naturally,  the  multi- 
plicity of  the  sites  and  the  varied  intensity  of  gastric  ulcer,  together 
with  the  presence  or  absence  of  perigastric  adhesions,  so  modify  these 
tender  points  that  it  is  not  surprising  that  sometimes  they  are  absent, 
but,  if  found,  they  are  a  great  aid  to  diagnosis. 


PHYSICAL   METHODS  OF   EXAMINATION   OP   THE   DIGESTIVE   TRACT        85 

Palpation  of  Parts  of  the  Normal  Intestinal  Tract. — As  applied  to 
the  stomach,  this  method  is  important  in  determining  the  outline 
of  that  organ,  as  well  as  in  detecting  whether  a  tumor  is  attached  to 
the  stomach.  When,  for  instance,  there  is  marked  emaciation  and  a 
canoe-shaped  abdomen,  which  may  arise  from  stenosis  of  the  cardia,  it 
has  been  claimed  that  the  pylorus  may  be  felt.  This  appears  under 
the  fingers  as  a  cylindrical  body,  2-7  cm.  above  the  navel,  either  lying 
horizontally  or  diagonally,  with  one  side  directly  upward  and  to  the 
left  and  the  other  downward  and  to  the  right,  as  large  as  the  finger 
or  thumb,  and  of  the  hardness-  of  cartilage.     Under  the  fingers  it 


Fig.  14. — Dorsal  pi-essure  point  in  chololithiasis. 

often  collapses  with  a  gurgling  sound,  and,  instead  of  the  cylinder, 
nodules  are  sometimes  felt.  The  author's  experience  has  been  that, 
while  with  gastroptosis  in  women  whose  abdominal  walls  are  very 
much  relaxed  a  point  may  be  found  where  by  the  sound  heretofore 
described,  aided  by  a  sense  of  touch,  one  is  assured  that  fluid  is  passing 
in  well-regulated  spurts,  indicating  the  pylorus,  his  fingers  have,  how- 
ever, never  been  able  to  grasp  it  fully.  This  fluid,  as  can  be  readily 
demonstrated,  is  passing  from  left  to  right  in  contradistinction  to  the 
course  of  the  colon.  It  is  evident  that  the  pylorus  is  in  a  state  of 
contraction  to  produce  his  phenomenon,  for  in  the  empty  stomach, 
when   it  is    collapsed,   this   sensation   is    almost   never   experienced. 


86  DISEASES  OF   THE   DIGESTIVE   TRACT 

Hausmann  has  given  certain  directions  for  carrying  out  this  effort  to 
feel  the  pylorus  and  other  parts  of  the  intestinal  tract,  which  he  calls 
deep  palpation.  It  consists  in  first  obtaining  complete  relaxation  of 
the  abdominal  walls,  which  Schmidt  declares  can  be  best  obtained  by 
asking  the  patient  to  press  his  head  into  the  pillow  as  hard  as  pos- 
sible while  lying  on  the  back,  thus  putting  the  back  muscles  on  the 
stretch  and  relaxing  the  recti,  which  prove  such  a  hindrance  to  deep 
palpation;  two  finger  tips  (second  and  third)  are  then  placed  between 
the  median  line  and  the  right  costal  border,  and  by  pressure  forced 
downward  until  they  reach  the  posterior  abdominal  wall,  reinforcing 
the  pressure,  if  necessary,  by  the  other  hand  passed  over  the  palpating 
fingers;  then  a  gliding  motion  downward  is  imparted  to  the  lower 
hand.  If  anything  is  felt,  we  try  to  note  its  consistency,  its  mova- 
bility  by  inspiration  and  its  fixation  by  the  hand  in  expiration,  the 
acoustic  phenomena  described  above,  and  its  size.  In  this  way  the 
colon  can  often  be  felt  as  a  firm  cord  lying  above  the  navel,  which 
is  very  important  for  the  detection  of  the  lower  border  of  the  stomach, 
and  can  be  distinguished  from  the  pylorus  by  lack  of  change  of 
consistency,  by  the  distance  downward  to  which  it  can  be  passively 
displaced,  and  by  its  greater  distance  to  the  right  of  the  median 
line,  to  which  it  can  be  followed.  In  a  similar  way  the  lower  border 
of  the  stomach  can  be  felt  just  above  the  colon  as  a  ridge  directed 
toward  the  feet,  which  recedes  from  the  fingers  on  expiration.  This 
ridge  or  band  differs  from  the  colon  and  pylorus  in  that  no  upper 
border  can  be  felt  as  can  be  in  the  last  two  mentioned.  In  addition  to 
this  point,  attention  has  also  been  called  to  ''expiratory  gurgling," 
which  can  be  elicited  by  palpating  the  greater  curvature,  provided  that 
there  is  fluid  in  the  stomach  and  that  the  palpating  finger  be  pushed 
until  it  meets  the  spinal  column.  Another  point  to  distinguish  be- 
tween the  stomach,  colon,  and  pylorus  is  that  the  latter  two  can  be 
"fixed" — that  is,  held  during  expiration — while  the  stomach  cannot, 
since  it  is  impossible  in  a  normal  stomach  to  reach  its  upper  border  be- 
cause it  is  under  the  costal  arches.  This  statement  does  not,  how- 
ever, eliminate  the  possibility  of  holding  tumors  of  the  greater  curva- 
ture under  these  conditions.  In  case  of  any  doubt,  whether  we  have 
a  contracted  collapsed  stomach  or  the  colon  under  our  fingers,  it  is 
only  necessary  to  inflate  the  stomach  with  an  effervescent  mixture  to 
clear  up  the  matter,  as  a  distended  stomach  bears  no  comparison  to  the 
colon.  After  all  is  said  and  done,  mistakes  will  occur,  even  when  the 
greatest  care  is  employed,  as  in  one  of  the  author's  eases,  where  the 
suspected  pylorus,  on  account  of  its  horizontal  and  lengthened  con- 


PHYSICAL,   METHODS   OF   EXAMINATION   OF    THE   DIGESTIVE   TRACT       87 

tour,  turned  out  to  be  the  lower  border  of  a  gallbladder  containing 
three  stones.  True  it  is  that  the  upper  border  could  not  be  felt  on 
account  of  the  spasm  of  the  muscle,  but  the  stomach  was  clearly  a  pro- 
lapsed one,  and  the  position  of  the  gallbladder  was  not  inconsistent 
with  the  suspected  pylorus.  The  pancreas  is  probably  never  felt,  ex- 
cept in  very  extreme  cases  of  emaciation  and  relaxation  of  the  ab- 
dominal walls.  The  author's  experience  is  limited  to  only  one  case, 
which  was  a  marked  instance  of  splanchnoptosis,  accompanied  by 
periodical  attacks  of  pain,  followed  by  mild  jaundice,  in  which  there 
was  a  certainty  that  the  pancreas  was  under  his  fingers.  Its  lack  of 
movability  by  respiration,  our  inability  to  change  its  position  by 
manual  manipulation,  its  freedom  from  change  of  consistency,  and 
acoustic  phenomena  protect  us  from  mistaking  it  for  any  other  organ. 
During  digestion,  however,  the  physiological  contractions  of  the 
antrum  pyloricum  give  the  examining  finger  the  impression  of  a 
cylindrical  body  lying  to  the  left  or  across  the  median  line,  at  varying 
distances  above  the  navel,  which  has  been  mistaken  by  the  author  for 
the  pancreas,  but  in  a  short  time  relaxation  occurs  and  the  mistake  is 
self-evident.  It  is  sometimes  difficult  to  determine  whether  we  are 
dealing  with  a  pathological  contraction  or  spasm  of  the  pylorus  be- 
cause contractions  follow  each  other  with  such  rapidity  that  appar- 
ently no  relaxation  takes  place.  When,  however,  a  continuous  con- 
traction of  over  a  minute's  duration,  with  a  hard,  rigid  cylinder,  ex- 
ists, easily  perceptible  to  touch,  the  pylorus  is  undoubtedly  in  a  state 
of  abnormal  spasm.  E.  Schuetz  does  not  believe  that  such  a  spasm 
can  arise  from  pure  hyperacidity,  or,  as  we  prefer  to  call  it,  hyperse- 
cretion, but  must  arise  from  some  organic  changes  in  the  pylorus 
itself  or  in  its  neighborhood.  This  spasm  of  the  pylorus,  too,  may 
be  accompanied  by  pain,  under  which  condition  it  is  usually  due  to 
ulcer,  or  it  may  be  painless  as  the  result  of  malignant  disease.  Apart 
from  the  transverse  colon,  whose  palpation  has  been  described,  many 
other  portions  of  the  intestine  can  be  felt — the  cecum,  with  the  at- 
tached portion  of  the  ascending  colon,  the  descending  colon,  and 
less  often  the  sigmoid  on  account  of  its  changing  position.  The 
hepatic  and  splenic  flexures  cannot  be  felt  because  covered  by  the 
costal  arches.  The  small  intestine,  too,  eludes  palpation  in  its  normal 
condition.  The  palpable  parts  of  the  large  intestine  appear  to  the 
finger  as  a  more  or  less  firm  cord,  whose  thickness  depends  on  its 
content  and  degree  of  contraction.  To  the  novice  this  appears  like  a 
pathological  condition,  since  the  more  contracted  it  is  the  more  per- 
ceptible it  becomes.     If,  however,  the  palpating  finger  is  allowed  to 


88        .  DISEASES   OF   THE   DIGESTIVE   TRACT 

remain  in  contact  with  this  cordlike  body,  sooner  or  later  it  should  be 
felt  to  relax,  the  rigidity  disappears,  and  there  occur  gurgling  sounds 
on  movements  of  the  finger.  It  is  very  rare  that  the  whole  colon  is 
found  in  this  state  of  contraction,  but  the  latter  is  confined  to  localized 
sections.  It  has  been  demonstrated  that  palpation  of  the  intestine 
produces  no  unpleasant  sensation,  provided  it  is  free  from  disease. 
The  surface  of  the  colon  always  feels  smooth,  except  where  scybala, 
as  sometimes  occurs,  are  present  in  the  sigmoid,  descending  colon,  and 
occasionally  in  the  transverse.  A  special  indication  of  these  fecal 
masses  is  their  compressibility  and  the  sudden  separation  of  the  in- 
testinal wall  from  them  when  the  finger  is  slowly  withdrawn.  The 
existence  of  the  latter  peculiarity  is  doubted  by  some  physicians,  and 
in  a  busy  clinic  it  is  often  more  satisfactory  to  note  the  point  at  which 
the  masses  are  found,  and  to  send  the  patient  away  with  advice  to  take 
a  good  dose  of  castor  oil  and  to  return  in  a  couple  of  days,  when  some- 
times, much  to  one's  surprise,  the  masses  have  disappeared,  thus 
proving  their  fecal  origin.  The  most  difficult  factor  in  palpation  of 
sections  of  the  intestine  is  to  determine  whether  the  contracted  por- 
tion that  is  felt  is  pathological,  or  if  the  distended,  apparently  atonic, 
fragment  is  abnormal.  The  rontgenologists  have  shown  us  so  often 
contracted  portions  of  the  intestine  in  one  picture,  containing  prac- 
tically none  of  the  bismuth  mixture,  which  are  amply  filled  in  the 
next,  that  our  indecision  is  not  to  be  wondered  at.  AVhen,  however, 
our  eyes  observe  a  permanent  meteorism  and  rigidity  before  the  sec- 
tion of  the  intestine  which  is  palpable,  there  can  be  no  doubt  of  a 
pathological  narrowing. 

Palpation  of  Tumors. — Here  we  must  distinguish  between  true 
tumors,  occasioned  by  real  anatomical  diseases,  and  pseudo  tumors. 
The  latter,  again,  can  be  divided  into  apparent  tumors,  which  do  not 
give  us  the  impression  of  anatomical  or  functional  pathological 
changes,  and  phantom  tumors,  which  are  due  to  functional  patho- 
logical changes.  An  apparent  tumor  is  often  the  result  of  a  con- 
traction of  the  recti,  by  which  there  is  a  protrusion  of  a  mass  of  muscle 
lying  between  two  adjacent  lineag  transversa,  especially  in  the  upper 
portion  of  the  abdomen.  These  are  not  mistaken  only  by  beginners 
for  pathological  new  growths,  and,  while  they  usually  appear  in 
nervous  individuals  at  the  first  examination,  in  one  case  under  the 
author's  observation  the  spasm  persisted  up  to  the  time  when  the 
muscle  was  relaxed  by  anesthesia  at  the  exploratory  operation,  which 
disclosed,  on  opening  the  abdomen,  a  chronic  gastric  ulcer,  which  was 
not  connected  in  any  way,  either  by  locality  or  adhesion,  with  the 


PHYSICALi  METHODS  OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT       89 

masses  which  had  been  felt.  Apart  from  these  local  contractions  of 
portions  of  a  muscle,  we  may  have  true  spasms  of  the  recti,  the  real 
phantom  tumors,  in  nervous  and  hysterical  persons  with  exaggerated 
reflexes.  These  spasms  may  be  spontaneous  or  brought  about  by  the 
lightest  touch  on  the  abdominal  wall,  or,  they  may  result  from  actual 
disease  of  the  central  nervous  system.  Such  spasms  of  sections  of 
the  recti,  which  actually  overlie  diseased  painful  organs — like  a  stom- 
ach with  ulcer  or  cancer,  an  inflamed  gallbladder,  or  any  inflamed 
appendix  (defense  musculaire) — may  occur.  About  the  only  way  to 
differentiate  the  latter  from  the  purely  nervous  spasm,  or  to  investi- 
gate the  organ  underneath,  is  to  examine  in  forced  inspiration  or  in  a 
hot  bath.  We  often,  while  palpating,  especially  with  very  relaxed 
abdominal  walls,  come  upon  the  aorta,  but  its  course  and  pulsations 
keep  us  from  error,  though  we  must  remember  that  a  growth  attached 
to  the  pylorus  often  lies  upon  the  aorta,  whose  pulsations  are  im- 
parted to  the  tumor.  The  true  tumors  of  the  stomach,  on  account 
of  their  great  mobility,  may  be  found  in  almost  any  part  of  the  ab- 
domen, K.  Schmidt  reporting  a  case  of  gastric  cancer  where  the  mass 
was  found  under  the  left  costal  border,  yet  most  of  them  are  found 
in  the  area  bounded  by  the  costal  arches  and  the  transverse  umbilical 
line.  They  may,  however,  lie  even  below  the  navel  to  the  right  or 
left  of  the  median  line.  The  position  of  such  a  tumor  is  dependent 
also  on  the  state  of  fullness  of  the  stomach;  for  instance,  a  mass  may 
be  found  well  to  the  left  of  the  median  line  when  the  stomach  is 
empty,  but  after  a  meal,  or  on  giving  an  effervescent  mixture  to  in- 
flate the  stomach,  the  mass  will  be  found  well  to  the  right — at  the 
usual  site  of  the  pyloric  tumor.  It  is  well  to  remember  that  the 
pylorus  and  lesser  curvature  are  the  usual  sites  for  both  cancer  and 
ulcer.  It  is  often  very  difficult  to  determine  by  palpation  the  size 
of  the  growth,  since  the  portion  that  can  be  felt  is  dependent  on 
the  state  of  relaxation  of  the  abdominal  muscles,  the  region  of  the 
stomach  in  which  it  is  situated,  and  the  amount  of  contents  contained 
within  it  and  the  neighboring  intestines,  and  for  these  various  reasons 
it  seldom  happens  that  tumors  can  be  wholly  grasped.  The  most 
satisfactory  examination  in  the  author's  experience  was  in  an  elderly 
man,  through  whose  upper  abdomen  there  was  a  huge  hernia,  result- 
ing from  a  gallstone  operation  of  ten  years  before,  and  in  this  pouch, 
undeterred  by  the  rectus,  a  tumor  of  the  pylorus  could  be  grasped,  en- 
tirely encircled  by  the  fingers,  and  moved  in  almost  any  direction. 
All  the  other  accompaniments  of  a  gastric  cancer  were  present  in  this 
elderly  man.     Under  ordinary  conditions,  then,  it  is  not  surprising 


90  DISEASES   OF   THE   DIGESTIVE   TRACT 

that  many  gastric  tumors  evade  palpation,  and  this  is  particularly 
true  of  those  near  the  cardia,  posterior  surface,  and  lesser  curvature 
of  the  stomach.  These  tumors,  if  malignant,  usually  have  a  hard, 
firm  feel,  like  cartilage,  and  are  roughened  and  granular  to  the  touch, 
though  they  may  sometimes  be  smooth.  Those  tumors  caused  bj^  cal- 
lous ulcers,  or  by  perigastric  adhesions  accompanying  ulcers,  may  have 
all  grades  of  consistency  and  roughness.  They  may  feel  smooth  or 
granular,  flat  or  cordlike;  in  fact,  the  mere  attachment  of  a  growth 
to  the  stomach  gives  one  no  information  as  to  its  character.  Most 
tumors  of  the  stomach  are  characterized  by  extreme  tenderness  on 
palpation,  except  the  pyloric  spasm  dependent  on  cancer,  which,  as 
stated,  may  prove  entirely  free  from  sensitiveness.  In  most  cases  gas- 
tric tumors  show  a  surprising  amount  of  mobility,  W'hich  can  be  demon- 
strated by  change  of  position  on  the  part  of  the  patient,  distention 
of  the  stomach  by  effervescent  mixture,  or  displacement  by  manual 
manipulation.  This  is  especially  true  w^hen  they  are  attached  to  the 
pylorus  or  the  greater  curvature  in  a  low-lying  stomach,  as  is  its  usual 
position  under  these  conditions.  Those,  too,  w^hich  can  be  moved 
about  with  the  fingers  show  a  remarkably  spontaneous  change  of  posi- 
tion with  the  ordinary  peristalsis  of  the  stomach  entirely  apart  from 
its  state  of  fullness;  in  fact,  they  may  sometimes  entirely  disappear. 
Furthermore,  this  class  may  be  recognizable  only  in  certain  positions 
of  the  patient,  as  lying  on  the  left  or  right  side,  or  in  erect  position, 
etc.  When  the  tumor,  as  often  happens,  becomes  adherent  to  neigh- 
boring organs,  like  the  pancreas,  liver,  or  intestine,  its  mobility  may  be 
lost.  The  gastric  tumor  may  also  show  marked  change  of  position 
with  the  different  stages  of  respiration  w'hen  the  prolapse  of  the 
stomach  has  not  gone  so  far  as  to  separate  it  too  far  from  its  .juxta- 
position to  the  diaphragm  and  its  consequent  participation  in  the 
movements  of  the  latter.  This  respiratory  change  of  position  of  the 
growth  is  more  marked  the  nearer  it  is  to  the  diaphragm,  so  that 
tumors  of  the  smaller  curvature  possess  this  quality  in  a  marked  de- 
gree, while  those  of  the  greater  curvature  or  the  pylorus  are  less  sus- 
ceptible to  change  of  position,  unless  the  pylorus  becomes  adherent 
to  the  liver,  when  this  quality  is  restored  to  it  in  its  fullest  extent. 
When  the  tumor  can  be  grasped  by  the  fingers  from  above,  it  can 
be  held  in  any  stage  of  the  expiration,  and  hence  our  inability  to  hold 
it  fast  is  only  secondary  to  our  inability  to  get  our  fingers  above  it. 
R.  Schmidt  remarks  that  it  augurs  ill  for  the  athletic  prowess  of 
the  examiner  if  he  cannot  hold  such  tumors  fast  in  expiration,  pro- 
vided he  can  only  get  his  fingers  above  them.     This  quality  is  often 


PHYSICAL   METHODS  OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT       91 

of  great  value  in  distinguishing  growths  of  the  liver  and  gallbladder 
above  which  one  cannot  get  his  fingers — that  is,  they  are  not  sus- 
ceptible to  expiratory  fixation — and  those  of  the  stomach,  over  which 
one  can  place  his  fingers.  Still,  when  gastric  tumors  become  attached 
by  adhesion  to  the  liver,  they  lose  this  quality,  and  some  pyloric 
tumors  never  possess  it.  On  inflation  of  the  stomach,  as  previously 
stated,  the  position  of  the  tumor  attached  to  it  changes  its  position 
very  decidedly.  The  pyloric  variety  move  from  the  left  toward  the 
right,  and,  in  some  cases  in  the  author's  experience,  completely  across 
the  median  line  and  downward.  Those  of  the  lesser  curvature,  since 
the  stomach  turns  on  its  transverse  axis,  become  less  distinct  and 
sometimes  entirely  disappear.  Tumors  of  the  posterior  wall  entirely 
disappear,  and  those  of  the  anterior  become  more  prominent.  As  to 
the  character  of  the  gastric  tumor  when  discovered,  whether  benign  or 
malignant,  palpation  gives  us  but  little  aid  unless  metastasis  can 
be  found.  A  callous  ulcer,  with  more  or  less  adhesions,  will  give  the 
same  impression  to  the  examining  finger  as  a  cancer;  in  fact,  even 
when  the  abdomen  is  opened,  it  is  not  easy  to  differentiate  without  a 
histological  examination  of  a  section.  In  two  instances,  to  the  author 's 
chagrin,  such  masses  in  individuals  over  50  years  of  age,  with  marked 
emaciation  and  visible,  palpable  gastric  rigidity,  have  been  pro- 
nounced malignant,  operation  refused,  and  life  prolonged  for  three 
years  to  his  knowledge,  though  pyloric  stenosis  persisted,  with  a  fair 
share  of  health.  In  the  effort  to  determine  whether  a  mass  attached 
to  the  stomach  is  a  benign  or  malignant  growth,  we  should  never  neg- 
lect the  palpation  of  the  inguinal,  umbilical,  or  supraclavicular  region, 
particularly  the  left,  for  enlarged  glands.  When  cancer  of  the  stom- 
ach exists,  these  glands  are  enlarged  and  hard  from  the  formation 
of  metastases,  and  such  evidence  has  a  great  value  both  from  a  diag- 
nostic and  prognostic  point  of  view.  The  inguinal  and  clavicular 
glands  are,  however,  only  rarely  enlarged  in  gastric  cancer,  and  may 
be  involved  from  malignant  disease  of  other  abdominal  organs,  or 
even  in  other  diseases,  so  that  this  diagnostic  point  has  its  limitations. 
The  enlarged  umbilical  glands  consist  of  several  hard,  isolated  kernels, 
as  large  as  a  pea  or  hazelnut — either  above  or  below  the  navel,  or  sur- 
rounding it — which  is  the  usual  appearance.  We  may,  however, 
observe  a  very  hard,  firm  infiltration  of  the  entire  navel,  completely 
obliterating  its  contour,  which  is  the  much  less  common  form.  Un- 
fortunately, both  forms  of  involvement  come  so  late  in  malignant  dis- 
ease that  we  can  usually  make  the  diagnosis  without  their  aid.  More 
recently  attention  has  been  called  to  the  enlargement  of  glands  in 


92  DISEASES   OF   THE   DIGESTIVE   TRACT 

Douglas'  pouch  in  those  afflicted  with  gastric  cancer.  These  are 
found  on  the  anterior  wall  of  the  rectum,  above  the  prostate  in  man 
or  the  uterus  in  woman;  furthermore,  they  may  assume  an  annular 
form,  even  at  times  causing  stenosis.  These,  if  found,  are  a  great 
aid  where  the  gastric  growth  cannot  be  palpated,  and  their  presence, 
of  course,  precludes  the  advisability  of  operation,  unless  undertaken 
for  purely  palliative  purposes.  After  searching  for  these  glands,  in 
every  case  of  gastric  cancer  coming  under  the  author's  observation, 
his  opinion  is  that  they  are  extremely  rare.  Again,  it  rarely  happens 
that  metastasis  may  be  found  in  the  right  or  left  ovary,  as  in  one 
case  of  the  writer's,  where  the  right  ovary  was  involved.  Mean- 
while, tumors  of  neighboring  organs,  like  the  gallbladder,  may  simu- 
late very  closely  a  gastric  growth,  and  can  be  differentiated  only  by 
inflation  of  the  stomach  or  the  x-ray  picture.  Particular  care  should 
be  taken  not  to  mistake  an  epigastric  hernia  for  a  gastric  tumor. 
These  small  protrusions,  rarely  larger  than  a  bean  or  a  grape,  are 
especially  distinguishable  by  the  fact  that  they  can  be  replaced  wholly 
or  partially  by  the  finger.  In  fact,  in  the  prone  position  they  often 
spontaneously  disappear,  to  reappear  on  coughing  or  bearing  down  as 
at  stool ;  if,  during  this  act,  one  attempts  to  press  them  back,  a  peculiar 
crackling  sensation  is  imparted  to  the  finger,  much  like  the  pleuritic 
or  peritoneal  rub.  This  is  apparently  due  to  forcing  the  uneven 
surface  of  the  hernia  by  the  sharp  edges  of  the  opening  into  the  con- 
tracted fasciae  of  the  linea  alba.  These  hernias  can  often  be  de- 
tected only  when  the  patient  is  in  an  erect  position.  Such  a  small, 
insignificant  protrusion  must  be  reckoned  with  when  patients  com- 
plain of  painful  sensations  in  the  epigastrium,  for  they  exert  a  dele- 
terious effect  by  pinching  a  bit  of  the  peritoneum  or  adjacent  nerves, 
or,  reflexly,  by  keeping  up  a  gastric  neurosis.  i\Iany  of  them  are,  how- 
ever, discovered  accidentally  when  no  gastric  symptoms  are  complained 
of,  as  in  emphysema,  where  there  is  an  almost  constant  inefficient 
cough.  Furthermore,  one  should  never  be  satisfied  wdth  the  mere  dis- 
covery of  such  a  hernia  without  employing  all  other  means  of  exami- 
nation for  other  possible  causes  of  gastric  distress.  It  will  not  do 
to  leave  this  subject  without  speaking  of  the  possible  association  as 
cause  and  effect  between  the  small  ruptures  and  gastric  ulcers.  This 
connection  is  claimed  by  many  as  having  been  established.  Of  course, 
on  account  of  their  frequency,  there  must  be  many  occasions  where 
they  are  present  together  with  an  ulcer,  but  in  the  writer's  experi- 
ence their  coexistence  has  been  only  a  coincidence.  It  is  much  more 
reasonable  to  suppose  that  the  weakness  of  the  fascia  is  congenital. 


PHYSICAL.   METHODS  OF   EXAMINATION   OP   THE  DIGESTIVE  TRACT       93 

and  that  the  hernia  appears  as  a  result  of  increased  intraabdominal 
pressure  due  to  persistent  cough  or  heavy  lifting.  Then,  again,  they 
often  become  visible  and  palpable  through  rapid  loss  of  flesh,  though 
they  may  have  existed  for  many  years.  Mobility  of  a  tumor  in  the 
intestine,  is  largely  dependent  on  the  segment  involved  and  its  re- 
lation to  the  mesentery,  provided  that  no  adhesions  have  formed; 
hence  tumors  of  the  small  intestine  will  be  more  movable,  vrhile  in 
the  colon  only  those  growths  of  the  sigmoid  and  transverse  colon 
will  possess  this  characteristic  to  any  great  extent.  Tumors  of  the 
duodenum,  transverse  colon,  and  both  colic  flexures  may  possess  a 
moderate  amount  of  respiratory  motion,  but  those  below  the  navel  do 
not  possess  this  to  any  great  degree. 

PERCUSSION  OF  THE  GASTROINTESTINAL  TRACT. 

While  it  is  true  that  percussion  of  the  empty  stomach,  particularly  if 
it  contains  no  air,  is  futile,  because  in  its  collapsed  condition,  if  normal, 
it  recedes  under  the  left  costal  border  and  liver,  still,  unless  the  patient 
has  undergone  a  long  period  of  fasting,  or  there  is  an  esophageal  steno- 
sis, there  is  usually  enough  air  in  the  stomach,  swallowed  with  the  pre- 
vious meal,  to  give  fairly  good  outlines  on  percussion,  except  along  the 
upper  border.  These  outlines  are  still  more  accurately  defined  when 
there  is  a  moderate  distention  from  food.  This  can  also  be  exaggerated 
by  moderate  filling  of  the  organ  with  air  by  a  compression  bulb  or  with 
carbon  dioxide  by  means  of  the  effervescent  mixture.  The  filling  of 
the  stomach  with  fluid  (drinking  one  or  two  glasses  of  water)  and 
determination  of  the  lower  border  by  percussion,  with  the  patient  in 
the  erect  position,  have  also  been  recommended. 

Method. — It  is  always  best  to  have  the  patient  on  the  back,  because 
the  abdominal  muscles  are  better  relaxed,  and  the  use  of  the  finger 
is  to  be  recommended,  since  a  much  lighter  blow  can  be  struck  with 
it  than  with  the  percussion  hammer — a  matter  of  no  little  importance 
when  we  are  trying  to  distinguish  the  slight  differences  in  tone  be- 
tween the  colon  below,  or  the  small  intestine  to  the  right,  and  the 
stomach.  For  this  purpose  the  finger  used  as  a  pleximeter  should  be 
applied  very  lightly  to  avoid  the  tone  of  deep-lying  organs.  Begin- 
ning at  the  fifth  rib,  one  should  percuss  downward  on  the  left  side  of 
the  patient  in  three  parallel  lines — the  parasternal,  midclavicular,  and 
anterior  axillary — marking  with  a  pencil  the  upper  and  lower  limits 
of  the  gastric  tympany,  a  note  easily  recognized ;  then,  beginning  be- 
low the  level  of  this  line,  marking  the  lower  border  and  extending  to 


94  DISEASES   OF   THE   DIGESTIVE   TRACT 

the  right,  percuss  upward  and  toward  the  left  in  converging  lines 
until  the  right  border  of  the  stomach  is  delineated  on  the  skin  with 
a  pencil.  For  reasons  previously  stated,  it  is  impossible  to  mark  out 
the  upper  border  of  the  pyloric  portion  of  a  normal  stomach,  and 
the  left  border  similarly  eludes  us.  In  the  majority  of  cases  this 
method  gives  us  the  desired  information,  but  occasionally  it  is  al- 
most impossible  to  detect  any  marked  difference  in  the  tone  while  we 
are  percussing  over  the  stomach  and  the  adjacent  air-filled  organs, 
and  in  this  extremity  we  proceed  to  inflation  of  the  stomach  by  means 
of  air  introduced  through  the  stomach  tube,  during  which  we  can 
either  watch  the  distending  stomach  or  ask  the  patient  to  make  a 
signal  when  pressure  begins  to  be  felt,  or  we  may  give  the  effer- 
vescent mixture,  to  which  reference  has  often  been  made.  This  con- 
sists of  four  grams  of  tartaric  acid,  which  is  to  be  dissolved  in  half 
a  glass  of  water,  and  drunk  by  the  patient,  with  some  sugar  (if  the 
acid  taste  is  objectionable,  as  it  sometimes  is)  ;  and  then  in  a  second 
glass  five  grams  of  sodium  bicarbonate,  also  dissolved  in  half  a  glass 
of  water,  is  to  be  taken  either  at  once  or  in  two  portions,  with  an 
appreciable  pause  between,  so  that  the  stomach  shall  not  be  too  sud- 
denly distended.  After  this  the  patient  should  be  encouraged  not  to 
allow  the  gas  to  escape  by  belching,  and  should  lie  down  at  once  for 
examination.  In  the  clinic  one  learns  to  shake  out  of  a  bottle  into 
a  glass  practically  this  amount  of  the  two  powders  without  the  neces- 
sity of  weighing,  or  may  use  a  level  teaspoonful  of  each ;  at  least  no 
disadvantage  has  ever  arisen  in  the  writer's  experience  from  using  a 
trifle  too  much  of  this  mixture,  though  theoretically,  with  weakened 
gastric  walls  (ulcer  or  cancer),  such  procedure  might  cause  a  per- 
foration, but  in  these  very  cases,  particularly  on  account  of  probable 
stenosis,  it  is  unnecessary  to  employ  it,  since  the  stomach  is  usually 
well  distended.  It  is  not  advisable  to  attempt  to  use  the  effervescent 
mixture  in  a  fasting  stomach,  for  the  pylorus  is  relaxed  and  the  gas 
readily  escapes  into  the  duodenum.  The  best  time  is  shortly  after  a 
light  meal,  like  the  ordinary  breakfast.  This  medium  dose  of  the 
two  powders  is  to  be  recommended  rather  than  larger — which  latter 
overdistend  the  stomach,  produce  a  false  picture,  and  are  not  wholly 
harmless — or  smaller  ones,  which  are  perfectly  useless  for  the  purpose 
intended.  Both  these  methods,  and  the  x-ray  picture  of  the  stomach 
after  the  bismuth  mixture,  have  their  adherents,  but  the  former  is 
much  less  likely  to  produce  bizarre,  untruthful  outlines,  since  it  dis- 
tends the  organ  in  all  directions,  while  the  latter,  by  its  weight,  dis- 
tends the  most  dependent  portion.     Furthermore,  the  distention  with 


PHYSICAL   METHODS   OF   EXAMINATION   OF    THE   DIGESTIVE   TRACT       95 

gas,  if  the  amount  is  not  too  great,  gives  exactly  the  same  outlines  of 
the  stomach  that  are  obtained  by  other  methods,  and  one  can  often 
by  sight  alone  determine  the  borders  as  accurately  as  by  percussion. 
It  is  rare  that  a  patient  complains  of  any  discomfort  beyond  a  feel- 
ing of  pressure.  Only  twice  has  it  been  the  writer's  experience  to 
have  patients  complain  of  pain  and  nausea — one  a  condition  of  marked 
adhesions  about  the  pylorus,  and  the  other  a  gastric  cancer  with  in- 
volvement of  the  omentum.  Both  conditions  were  confirmed  by  opera- 
tion— the  latter  without  the  writer's  consent.  The  pain  complained 
of  is  usually  described  as  similar  to  that  which  spontaneously  occurs, 
an  excellent  proof  that  it  has  its  origin  in  the  stomach,  and  may  be 
due  to  adhesions,  as  described  above ;  to  irritation  of  an  ulcer,  or  to 
other  inflamed  condition  of  the  mucous  membrane;  to  spasm  of  the 
antrum  or  pylorus,  or  to  neurosis,  in  which  case  any  procedure,  such 
as  light  percussion  or  gentle  palpation,  causes  exclamations  of  pain. 
When  such  painful  sensations  are  produced,  it  is  usually  only  neces- 
sary to  have  the  patient  sit  up,  when  the  accumulated  gas  escapes 
with  an  explosive  sound ;  if  not,  the  introduction  of  the  stomach  tube 
(which  should  always  be  at  hand)  merely  into  the  esophagus  allows 
the  gas  to  escape,  which  is  followed  by  immediate  relief.  The  only 
circumstances  under  which  such  inflation  is  prohibited  is  an  active 
ulcer — that  is,  recent  hematemesis.  The  inflation  of  the  stomach  with 
air  has  never  proven  very  satisfactory  in  the  writer's  hands;  first, 
because  the  air  escapes  much  more  readily  through  the  pylorus,  while 
the  carbon  dioxide  causes  a  closure  of  the  latter;  second,  because  the 
air  produces  no  contraction  of  the  stomach,  while  carbon  dioxide  does, 
thus  establishing  a  second  factor — the  state  of  gastric  tonicity;  and 
last,  because,  unless  the  stomach  outlines  can  be  readily  seen,  it  really 
requires  an  assistant  to  inflate  with  the  double  syringe  while  the  ex- 
aminer percusses. 

Form,  Position,  and  Borders  of  the  Normal  Stomach. — In  Chapter 
I,  under  "The  Stomach,"  this  subject  has  been  touched  on  and  some 
reasons  given  for  the  almost  endless  contours  ascertained  by  different 
observers,  and  it  is  possible,  that  as  with  the  color  of  the  chameleon, 
all  are  right,  having  each  observed  the  stomach  under  different  con- 
ditions. The  factors  on  which  the  contour  of  the  stomach  depends  are 
its  elastic  walls,  which  allow  more  distention  in  one  direction  than  in 
another ;  its  autoinnervation,  which  permits  greater  contraction  in  one 
segment  than  in  another ;  the  shape  of  the  body — i.e.,  the  narrow  chest 
or  Stiller  type;  and  the  intraabdominal  pressure.  The  form  of  the 
stomach  differs  in  the  cadaver  from  that  in  the  living  object;  it  is 


96  DISEASES   OF   THE   DIGESTIVE   TRACT 

different  in  the  various  stages  of  fullness,  while  in  the  prone  position 
of  the  body  it  is  unlike  that  in  the  erect  attitude.  Three  general 
types  of  stomach  are  recognized,  which  are  here  portrayed  (Fig.  15). 

Simmonds,  from  many  photographs  of  the  stomach  in  cadavers,  has 
come  to  the  conclusion  that  there  is  no  clearly  defined  normal  form, 
but  that  many  variations  of  a  general  form  are  wholly  physiological. 
With  this  discussion  clinicians  have  little  to  do,  because  by  percussion 
we  can  map  out  only  the  upper  portion — or  bubble,  as  it  is  sometimes 
called — and  the  lower,  or  caudate  portion,  but  not  the  middle  sec- 
tion, which,  as  viewed  on  the  surface  of  the  body,  imparts  the  ap- 
pearance of  a  sack.  Still,  from  comparison  with  x-ray  pictures,  one 
must  recognize  that  this  method,  though  it  determines  only  the  lower 
and  right  borders,  gives  us  suflfieient  and  accurate  information  as  to 


Fig.  15. — Normal  form  of  the  stomach,      a,  according  to  Luschka;  h,  according  to  Rieder; 
c,  according  to  Holzknecht. 

position  and  size  of  the  stomach,  which  is  all  we  desire  for  a  clinical 
interpretation.  Hence  we  must  demand  a  rather  wide  departure 
from  the  limits  which  have  been  set  as  normal  before  we  can  pro- 
nounce a  stomach  dilated,  unless  symptoms  of  functional  impairment 
are  present,  for  there  exists  a  condition  known  as  megalogastria,  or 
eongenitally  large  stomach,  which  is  discovered  accidentally  and  is 
never  associated  with  impaired  motility.  The  prolapsed  or  tube- 
shaped  stomach,  filling  the  left  flank,  however,  can  hardly  be  regarded 
as  normal,  though  no  symptoms  are  present,  for  on  the  least  impair- 
ment of  general  health  we  begin  to  hear  complaints  of  gastric  dis- 
turbance from  those  possessing  the  organ  in  such  a  position.  All 
methods  of  determining  the  capacity  of  a  stomach  by  filling  it  with 
known  quantities  of  air  or  fluid  are  beset  with  so  many  errors  that 
but  little  clinical  information  can  be  obtained  from  them.  While, 
then,  firm  and  fixed  lines  concerning  the  borders  of  the  normal  stom- 


PHYSICAL   METHODS   OF    EXAMINATION    OF    THE    DIGESTIVE    TRACT       97 

ach  cannot  be  established,  yet,  with  moderate  distention  and  with 
the  patient  on  his  back,  the  following  approximate  borders  should  be 
regarded  as  normal :  the  upper  border  at  the  left  parasternal  line  is 
under  the  fifth  rib,  or  in  the  fifth  intercostal  space;  in  the  left  mam- 
mary line,  under  the  fifth  rib  or  sixth  intercostal  space;  in  the  left 
anterior  axillary  line,  under  the  edge  of  the  seventh  or  the  eighth 
rib.  The  left  gastric  border  cannot  be  accurately  determined,  while 
the  right  border  in  its  lower  part  is  5  cm.  from  the  median  line,  and 
often  inflation  of  the  stomach  may  extend  it  to  6  cm.  from  the  same 
line,  through  8  cm.  cannot  be  regarded  as  abnormal.  In  the  writer's 
estimation  the  most  characteristic  feature  is  the  extension  of  the  stom- 
ach tympany  on  the  right  side  above  the  costal  border,  which  has  been 
found  usually  to  mean  a  dilated  antrum,  and,  if  constant,  may  mean 
adhesions,  by  which  this  part  of  the  organ  is  not  allowed  to  recede 
as  the  food  leaves  it.  This  conclusion  has  also  been  verified  by  the 
x-ray  picture.  Occasionally  one  comes  upon  an  atonic  ileum,  accord- 
ing to  ^layr,  whose  distended  coils  may  simulate  strongly  the  dilated 
antrum  by  obscuring  the  lower  liver  dullness,  and  from  its  juxtaposi- 
tion to  the  antrum  makes  the  dividing  line  difficult  of  determination. 
That  author  claims,  however,  that  the  tympany  changes  from  the 
ordinary  high  tone  to  a  lessened  tone  when  we  percuss  across  the 
boundary  between  the  two  organs.  The  gastric  border  subject  to  the 
greatest  variation  is  the  lower.  The  reason  for  such  indefiniteness 
is  that  the  lower  border  is  dependent  on  age,  sex,  previous  pregnancies, 
general  build  of  the  body,  and  state  of  nutrition.  It  is  generally  con- 
ceded that  this  border  is  most  often  in  the  lower  third  of  a  line  drawn 
from  the  xiphoid  process  to  the  navel;  in  women  it  lies  a  little 
lower  than  in  men.  The  action  of  age  manifests  itself  by  bringing 
the  lower  border  in  children  less  than  15  years  of  age  down  to  the 
navel,  a  point  to  which  it  often  returns  again  at  the  age  of  50. 
Between  these  two  ages  no  influence  of  this  character  can  be  detected, 
and  previous  pregnancies  always  lower  this  border.  ]Muscularly  de- 
veloped and  well-nourished  men  usually  have  this  border  at  the  junc- 
tion of  the  middle  and  lower  third  of  this  line,  and  rarely  in  the  upper 
part  of  the  lower  third ;  this  point  is  at  a  distance  of  from  3-5  cm.  from 
the  navel  in  this  line.  Men  lacking  a  physical  development  and  poorly 
nourished  have  the  lower  border  in  the  lower  third  to  the  navel.  Well- 
nourished  women  have  the  lower  border  in  the  lower  third  and  poorly 
nourished  at  the  navel ;  hence  we  cannot  speak  of  pathological  changes 
unless  in  the  prone  position,  on  the  back,  the  lower  border  is  found 
at  the  navel  or  below  it. 


98  DISEASES   OP   THE   DIGESTIVE   TRACT 

Pathological  Changes  in  the  Gastric  Borders. — An  ascent  of  the 
upper  border  may  be  due  to  excessive  filling  of  the  stomach  with  gas, 
to  retraction  of  the  left  lung,  or  to  elevation  of  the  organ  in  toto — 
caused  by  abdominal  meteorism,  ascites,  or  a  tumor.  A  lowering  of 
the  upper  border  may  be  due  to  kyphosis,  as  in  one  case  reported  by 
the  author,  emphysema  (common),  and  an  accumulation  of  fluid  in 
the  left  pleural  cavity,  all  of  which  are  accompanied  by  a  lowering 
of  the  diaphragm.  Naturally,  a  prolapse  of  the  stomach  will  always 
be  accompanied  by  a  lowering  of  the  upper  border.  The  right  border 
may  sometimes  be  pushed  to  the  left  by  tumors  of  the  right  kidney,  or, 
as  R.  Schmidt  reports,  by  a  tumor  of  the  hepatic  flexure  of  the  colon. 
Tumors  of  the  liver,  however,  are  apt  to  push  the  stomach,  to  the 
rear ;  much  more  often  the  right  border  of  the  stomach  is  pushed  still 
farther  to  the  right — even  to  a  distance  of  9  cm.  from  the  median  line, 
due  to  dilatation  of  the  antrum  pylori,  whereby  there  is  always  pres- 
ent a  certain  degree  of  atony  and  impairment  of  the  advance  of  the 
digested  food  toward  the  duodenum.  Hence  this  advance  of  the  right 
border  of  the  stomach  still  farther  to  the  right  is  looked  on  by  many 
as  clinical  evidence  of  gastric  insufficiency.  According  to  Schuetz, 
the  extension  of  the  right  border  of  the  stomach  often  accompanies 
lack  of  motility,  but  is  not  an  invariable  concomitant.  The  elevation 
of  the  lower  border  may  be  due,  of  course,  to  the  same  causes,  which 
produce  the  same  condition  of  the  upper  border — viz.,  ascites,  meteor- 
ism, and  tumors  of  the  abdominal  walls.  Much  oftener,  however,  and 
of  much  more  diagnostic  importance,  is  the  lowering  of  the  lower  bor- 
der (below  the  navel  with  patient  on  his  back),  which  may  be  due  to 
prolapse  of  the  organ  as  a  whole,  or  to  enlargement  or  displacement 
of  the  stomach  in  a  vertical  direction  (so-called  tubular  stomach). 
Hence,  from  the  determination  of  the  lower  border  alone  we  cannot 
distinguish  the  position  of  the  stomach  or  whether  it  is  enlarged,  and 
to  this  we  must  always  add  the  establishment  of  the  other  borders 
for  any  clinical  interpretation.  Every  diminution  of  the  volume  of 
the  thoracic  cavity — whether  it  is  a  low-lying  diaphragm,  a  narrow- 
ing of  the  thorax  (particularly  the  lower  portion),  relaxation  of  the 
abdominal  walls,  or  insufficient  filling  of  the  intestines  on  which  the 
stomach  rests — will  cause  a  prolapse  of  the  stomach.  Thus  we  see 
that  many  agencies  may  act  in  depressing  the  lower  border  of  the 
stomach.  There  may  be  an  enlargement  of  all  the  dimensions  of  the 
organ,  known  as  ecstasy  or  megalogastria,  or  a  fall  of  the  organ  in 
toto;  in  the  latter  case,  there  is,  of  course,  a  lowering  of  both  the  upper 
and  lower  borders,  which  is  generally  known  as  true  gastroptosis. 


PHYSICAL.  METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT       99 

Then,  again,  we  may  have  the  upper  border  fixed  at  its  normal  height, 
but  the  lower  depressed,  or  a  partial  gastroptosis,  with  a  stretch- 
ing of  the  stomach  in  its  long  diameter.  This  peculiar  condition  is 
probably  only  simulated  by  the  dropping  of  the  pyloric  portion,  while 
the  cardia  remains  fixed,  for  on  inflation  one  can  often  see  the  organ 
lying  diagonally  across  the  abdomen,  with  the  pyloric  portion  point- 
ing toward  the  right  iliac  region.  The  most  varied  changes  in  posi- 
tion and  form  of  the  stomach  can  be  produced  by  tumors,  adhesions, 
and  retractions  dependent  on  scar  tissue.  The  most  marked  of  these 
clinically  is  the  hourglass  stomach  caused  by  the  contraction  fol- 
lowing the  healing  of  a  gastric  ulcer,  which  divides  the  organ  into 
two  separate  chambers,  with  a  narrow  opening  between,  often  admit- 
ing  only  the  forefinger.  ^Many  methods  have  been  devised  for  de- 
tection of  this  condition.  Sometimes  it  may  become  visible  by  in- 
flation if  the  abdominal  wall  be  thin,  but  the  newer  method  of  x-ray 
photography  after  the  bismuth  meal  has  proved  most  satisfactory. 
The  percussion-auscultation  method,  which  consists  in  placing  the 
stethoscope  over  that  portion  of  the  abdomen  where  tympany  is  most 
marked,  and  then  proceeding  outward  in  radial  lines  by  light  percus- 
sion or  by  friction  on  the  skin,  marking  with  a  pencil  the  point  where 
the  note  changes,  has  been  employed  to  mark  gastric  boundaries.  Un- 
fortunately, however,  the  distance  of  the  point  percussed  from  the 
stethoscope  bell  makes  a  marked  difference  in  the  note,  whether  one  is 
beyond  the  underlying  stomach  or  not,  so  that  the  method  is  not  to  be 
relied  on. 

Percussion  of  that  portion  of  the  abdomen  where  the  intestines  are 
supposed  to  lie  rarely  gives  any  definite  information  as  to  their  site  or 
condition.  Both  empty  portions  of  the  intestine  and  those  filled  with 
feces,  especially  those  parts  at  the  sides  of  the  abdomen,  may  give 
zones  of  dullness,  which,  if  relied  on,  lead  to  error.  With  intestinal 
meteorism  present,  those  distended  coils  afford  a  metallic  tone,  but 
this  is  obliterated  when  the  abdominal  walls  are  strongly  contracted. 
If  this  metallic  tone  remains  constant  at  a  certain  point,  it  indicates  a 
stenosis  of  the  gut  beyond,  but  it  is  not  absolute.  Nothnagel  has  called 
attention  to  the  fact  that,  if  the  narrowing  is  in  the  descending  colon, 
this  peculiar  note  is  better  elicited  over  the  loin  of  that  side  than  in 
front ;  with  stenosis  at  the  splenic  flexure,  this  can  be  obtained  over 
the  right  loin.  The  disappearance  of  the  hepatic  dullness  is  usually 
interpreted  as  meaning  accumulation  of  gas  in  the  peritoneum,  but, 
if  the  collection  of  gas  in  the  intestine  is  great  enough,  the  liver  can 
be  so  made  to  assume  the  horizontal  that  there  is  scarcely  any  liver 


100  DISEASES  OF   THE   DIGESTIVE   TRACT 

dullness  left.     Tumors  of  the  intestine  may  cause  a  localized  dullness, 
provided  that  the  distended  gut  does  not  overlie  them. 

AUSCULTATION  OF  THE  GASTROINTESTINAL  TRACT. 

Especially  in  the  digesting  stomach,  but  also  to  a  less  degree  during 
fasting,  certain  spontaneous  sounds  can  be  heard  with  the  stethoscope 
over  that  organ,  produced  by  setting  in  motion  air  and  fluid  through 
its  peristaltic  action.  These  may  be  regarded  as  pathological  when 
they  can  be  heard  without  an  instrument — in  fact  at  a  considerable 
distance  from  the  individual.  They  often  have  a  bubbling,  spurting, 
splashing  character,  sometimes  with  a  metallic  tone.  They  -usually 
mean  increased  peristalsis,  and,  as  they  are  more  often  heard  in 
women,  may  be  due  to  narrow  corsets  or  sometimes  even  to  pure  nerv- 
ousness. They  are  much  more  marked  with  increased  gas  content  of 
the  stomach,  which  may  be  produced  by  hasty  eating  and  drinking, 
by  which  more  air  enters  the  organ;  or  by  fermentation,  b^^  which 
gas  is  evolved.  In  many  eases  the  observation  has  been  made  that 
these  noises  occur  only  during  inspiration  and  expiration,  or,  if  the 
breath  is  held,  they  disappear.  In  one  instance  a  girl  who  had  suf- 
fered for  years  from  dyspeptic  symptoms,  and  in  whom  the  noises 
could  be  heard  at  a  distance  of  several  feet,  there  was  evidently  an 
hourglass  stomach  present,  and  the  sound  was  produced  by  the  air 
rushing  through  the  narrow  opening  on  respiration.  In  another  case 
the  x-ray  picture  showed  an  enlarged  gastric  bubble  at  the  upper 
portion  and  a  marked  depression  of  the  surface  of  the  bismuth  sus- 
pension with  every  inspiration.  Plere  there  was  a  dilated  stomach, 
with  marked  swallowing  of  air,  and  the  rush  of  air  into  the  bismuth 
mixture  caused  the  sounds ;  in  fact,  the  aerophagy  is  usually  to  be  re- 
garded as  the  cause.  Among  the  spontaneous  noises  of  the  stomach 
is  to  be  reckoned  the  so-called  belching  or  gaseous  eructations,  to 
which  reference  has  been  made  in  the  chapter  on  semiology  (Chapter 
III),  a  paroxysmal  succession  of  loud  explosive  sounds,  which  are 
caused  by  excess  of  contained  gas  due  to  fermentation  or  air  which 
has  been  voluntarily  or  involuntarily  swallowed;  or,  as  is  sometimes 
supposed,  where  there  is  an  insufficient  closure  of  the  pylorus,  the 
entrance  of  gas  from  the  intestine  into  the  stomach  takes  place. 
Most  often  it  manifests  itself  in  the  imperceptible  act  on  the  part 
of  nervous  or  hysterical  patients  of  swallowing  air — true  aerophagy. 
In  those  habituated  to  this  custom,  which  has  its  analogy  in  the  ''crib- 
bing" of  the  horse,  the  air  enters  the  esophagus  only,  without  reaching 


PHYSICALi   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE  TRACT       101 

the  stomach,  and  we  have  swallowing  and  noisy  ejections  alternately 
— the  same  volume  of  air  being  swallowed  and  discharged.  In  other 
cases  the  air  swallowed  enters  the  stomach  until  the  intragastric  pres- 
sure forces  it  out  with  a  noise  like  air  released  from  a  compressor; 
again,  it  may  be  sucked  into  the  stomach  with  inspiration  where  the 
cardia  is  relaxed.  Often  there  is  in  dyspeptics  a  sense  of  fullness 
which  they  think  they  can  overcome  by  efforts  at  eructation,  unaware 
that  with  each  effort  they  swallow  as  much  air  as  they  eject,  or  pos- 
sibly, by  increasing  the  intragastric  pressure,  are  able  to  remove  the 
gas  which  previously  did  not  have  tension  enough  to  cause  the  stomach 
to  contract.  It  is  noticeable  that  patients  often  declare  that  a  glass 
of  soda  water^charged,  as  we  know,  with  gas — will  often,  when 
drunk,  afford  relief.  That  in  many  cases  this  act  is  purely  voluntary 
is  proven  by  the  energy  with  which  the  act  is  practiced  by  patients 
in  a  clinic  who  wish  to  impress  the  physician  with  the  severity  of 
their  suffering.  Not  all,  however,  who  practice  this  act  are  to  be 
regarded  as  neurotics,  for  often  a  careful  examination  will  discover  a 
gastric  disorder  whose  relief  checks  the  eructation;  the  other  class 
will  usually  cease  when  their  attention  is  called  to  the  futility  of  it 
as  a  means  of  relief.  Among  these  sounds  there  is  one  group  which 
has  a  real  diagnostic  importance,  known  as  the  deglutition  sounds.  If 
we  place  a  stethoscope  over  the  epigastrium  or  over  the  tenth  or 
twelfth  thoracic  vertebra  behind,  and  the  patient  be  asked  to  swallow 
a  mouthful  of  water,  two  sounds  are  heard,  the  first  immediately  after 
the  act  itself  and  the  second  a  few  seconds  later.  According  to 
IMeltzer,  the  first  is  caused  by  the  forcing  of  the  fluid  into  the  esopha- 
gus by  the  contraction  of  the  pharyngeal  muscles  and  the  second  by 
the  liquid,  accumulating  above  the  closed  cardia,  being  forced  gradu- 
ally through  this  opening  into  the  stomach.  When  the  esophagus  is 
narrowed  by  a  stricture,  the  second  sound  is  very  much  delayed,  or 
may  not  be  heard  at  all.  Unfortunately,  as  this  sound  may  fail  to 
occur  in  perfectly  normal  individuals,  its  value  as  a  diagnostic  point 
is  somewhat  impaired.  Since  we  have  had  the  x-ray  the  importance 
of  this  sign  has  been  lessened,  though  recently,  in  the  writer's  expe- 
rience, the  second  sound  was  lacking  in  an  individual  in  whom  the 
radiogram  showed  no  stricture,  but  at  the  exploratory^  operation 
the  surgeon  reported  a  large  malignant  mass  high  up  in  the  lesser 
curvature  which  involved  the  cardia.  At  least  we  may  say  that,  if 
the  second  sound  is  heard  distinctly  and  without  delay,  there  can  be 
no  narrowing  at  the  cardia.  Schuetz  warns  us  against  listening  for 
this  second  sound  while  the  patient  is  lying  down,  for  in  this  case  a 


102 


DISEASES   OF   THE   DIGESTIVE   TRACT 


series  of  splashing,  broken  sounds  are  heard,  which  are  dependent  on 
the  fact  that  the  fluid  does  not  drop  directly  to  the  cardia,  but  flows 
gradually  along  the  posterior  wall  of  the  esophagus.  There  are  often 
heard  over  the  pylorus  at  the  end  of  a  contraction  phase,  or  in  the 
interval  between,  particularly  if  much  fluid  has  been  taken,  various 


16. — Stomach  with  malignant  disease  of  the  cardia. 

George.) 


(From   collection  of  Dr.  Arial  W. 


spurting,  gurgling  sounds  which  are  not  to  be  regarded  as  indicative 
of  a  pathological  condition,  but  in  the  writer's  experience  are  much 
more  noticeable  when  the  exit  of  the  stomach  has  dropped,  bringing 
it  nearer  the  abdominal  wall.  They  follow  each  other  at  regular  in- 
tervals,  and   are  valuable   only  in   determining  the   position   of  the 


PHYSICAL   METHODS  OP   EXAMINATION   OP   THE   DIGESTIVE   TRACT       103 

pylorus,  as  is  the  point  in  the  chest,  where  the  first  cardiac  sound  is 
loudest,  for  marking  the  probable  site  of  the  heart's  apex.  These 
sounds  are  also  useful  at  times,  on  account  of  their  regularity,  in  dif- 
ferentiating a  contracted  palpable  pylorus  from  a  section  of  the 
intestine  which  may  be  felt.  Auscultation,  too,  may  be  employed  in 
determining  the  lower  border  of  the  stomach,  after  the  effervescent  mix- 
ture is  taken,  by  listening  at  different  points  in  a  downward  direction 
until  the  hissing 'sounds  made  by  the  bubbles  are  no  longer  heard, 
which  point  marks  the  lower  border  of  that  organ.  It  has  been  recom- 
mended that  only  a  gram  each  of  tartaric  acid  and  sodium  bicarbonate, 
dissolved  separately  in  25  c.c.  of  water,  be  taken,  so  that  the  evolution 
of  gas  will  be  less  violent,  that  the  patient  remain  in  an  erect  posi- 
tion, and  that  we  listen  with  the  ear  against  the  abdominal  wall  in- 
stead of  with  a  stethoscope.  The  point  at  which  the  hissing  sound  is 
most  distinct  is  to  be  regarded  as  the  lower  border  of  the  stomach, 
since  the  fluid  gravitates  to  that  point.  One  great  advantage  of  this 
method  is  that  we  may  learn  the  position  of  the  stomach  when  the 
patient  is  in  the  erect  posture,  which  of  necessity  must  be  much  lower 
than  when  he  is  prone.  One  can  easily  combine  this  method  with  that 
of  Fuld  for  determining  the  presence  of  acid  in  the  stomach  by  giving 
the  bicarbonate  solution  alone ;  then,  if  no  effervescence  is  heard  (ab- 
sence of  acid),  the  tartaric  mixture  may  be  taken. 

SUCCUSSION  SOUNDS. 

When  air  and  a  fairly  large  amount  of  fluid  are  present  in  the 
stomach,  we  may  produce  sounds  by  sharp,  short,  downward  blows 
on  the  abdomen  over  the  stomach  with  the  tips  of  the  curved  fingers, 
comparable  to  the  noise  produced  by  shaking  air  and  water  in  a  bottle, 
the  so-called  slopping  or  succussion  sounds.  Sometimes  patients  can 
also  produce  them  by  quick,  forcible  inspiration,  or  often  complain 
that  the  sounds  are  heard  when  walking  or  rocking  in  a  chair.  Oser 
was  probably  the  first  to  make  use  of  these  sounds  for  the  detection 
of  the  lower  gastric  border.  In  order  to  accomplish  this,  one  must 
proceed  systematically,  with  short  pushes  with  the  tips  of  the  bent 
fingers  to  the  left  of  the  median  line,  vertically  downward,  as  long  as 
sounds  can  be  produced,  the  last  of  which  will  mark  the  lower  border; 
then,  beginning  at  the  left  at  the  point  where  the  sounds  were  loudest, 
proceed  to  the  patient's  right,  choosing  the  period  of  expiration  for 
the  blow,  and,  when  no  more  sounds  can  be  produced,  we  have  reached 
approximately  the  right  border.     These  sounds  can  be  elicited,  where 


104  DISEASES   OF   THE   DIGESTIVE   TRACT 

the  walls  are  not  too  thick,  in  perfectly  normal  stomachs,  and  they 
have  no  significance  except  the  aid  they  afford  to  the  determination  of 
the  position  and  size  of  the  organ.  The  succussion  sounds  can  be 
regarded  as  pathological  only  when  they  can  be  elicited  over  the 
organ  at  a  time  when  the  normal  stomach  is  supposed  to  have  passed 
its  contents  along  into  the  intestine — that  is,  twelve  hours  after  the 
evening  test  meal  consisting  of  soup,  meat,  potato,  bread,  and  butter, 
or  three  hours  after  the  test  breakfast  of  bread  and  water,  as  will 
be  more  fully  described  under  test  meals.  When,  after  these  in- 
tervals, succussion  can  be  distinctly  obtained,  it  means  that  the  fluid 
is  still  present  in  the  stomach,  and  indicates  either  a  retention  of  the 
contents  or  a  hypersecretion  of  gastric  juice.  Perhaps  it  is  well  to 
distinguish  between  splashing  produced  by  deep  and  fairly  forcible 
blows  on  the  abdomen — which,  as  stated  above,  can  have  no  value 
except  when  the  interval  after  the  last  meal  and  its  character  is 
taken  into  account — and  superficial  succussion  obtained  often  by  the 
lightest  touch  on  the  abdominal  wall.  The  latter  has  been  inter- 
preted as  meaning  a  relaxation  of  the  gastric  walls,  which  prevents 
the  organ  from  closing  firmly  around  its  contents.  An  objection  to 
this,  however,  is  presented  because  superficial  splashing  is  favored  by 
the  thinness  of  the  abdominal  walls  and  prolapse  of  the  stomach,  by 
which  a  larger  part  of  the  organ  lies  in  contact  with  said  wall,  thus 
introducing  two  other  factors.  Some  would  attempt  to  make  these 
conditions — thinned  abdominal  walls,  gastroptosis,  and  gastric  atony 
— always  allied,  and  no  doubt  the  former  two  do  encourage  the  ad- 
vent of  the  last  at  a  later  stage,  but  all  of  us  must  have  found  many 
times  thinned  belly  walls,  prolapsed  stomach,  and  loud  superficial 
splashing  without  the  slightest  evidence  of  atony  as  demonstrated  by 
gastric  insufficiency.  Furthermore,  it  has  been  the  author's  expe- 
rience that  by  treatment  the  insufficiency  due  to  atony  may  be  over- 
come, but  the  splashing  and  gastroptosis  continue.  Hence  it  can  be 
seen  that  these  splashing  sounds  do  not  necessarily  mean  gastric  atony, 
for  their  intensity  depends  on  the  greater  amount  of  gastric  surface 
in  contact  with  the  abdominal  wall;  in  fact,  with  pyloric  stenosis 
where  the  stomach  is  prolapsed  and  enlarged,  though  compensatory 
hypertrophy  of  its  walls  has  taken  place,  and  there  can  be  no  question 
of  atony,  loud  splashing  sounds  can  be  produced.  The  true  value  of 
these  sounds  rests  in  their  indicating  that  fluid  is  still  present  in  the 
stomach,  and  by  their  location  they  indicate  the  lower  and  right 
borders,  and  in  this  way  also  indicating  the  size  and  position  of  the 
organ.     We  cannot  leave  this  subject  without  saying  something  about 


PHYSICAL   METHODS   OP   EXAMINATION   OF   THE   DIGESTIVE   TRACT       105 

the  systolic  epigastric  murmurs  in  growths  of  the  stomach.  These  are 
heard  best  in  the  epigastrium,  and  R.  Schmidt  has  found  that  they 
are  more  distinct  on  expiration.  Outside  of  the  aortic  aneurisms  and 
Laennec's  hepatic  cirrhosis,  these  murmurs  are  always  significant  of 
gastric  cancer,  and  they  are  especially  valuable  when  palpatory  find- 
ings are  not  distinct.  In  expiration,  epigastric  depth  is  least  and 
the  aorta  is  brought  nearer  the  abdominal  walls,  w^hich  probably  ex- 
plains this  respiratory  peculiarity.  They  are  undoubtedly  due  to 
compression  of  the  aorta  by  the  growth,  since  they  are  more  readily 
distinguishable  when  the  stethoscope  is  pressed  down  more  firmly. 

As  far  as  the  intestines  are  concerned,  auscultation  offers  us  but 
little  assistance.  It  is  claimed  that,  in  perfectly  normal  individuals, 
at  from  four  to  seven  and  a  half  hours  after  food  is  taken,  rhythmical 
sounds  can  be  heard  over  the  cecum  due  to  the  passage  of  the  con- 
tents through  the  ileocecal  valve.  Then,  too,  we  have  the  tormina  in- 
testinorum  in  nervous  individuals,  which  are  loud  gurgling  sounds, 
often  heard  at  some  distance  from  the  patient,  and  have  the  same  sig- 
nificance as  those  heard  over  the  stomach.  Similar  sounds,  but  appear- 
ing periodically,  can  be  heard  in  intestinal  stenosis,  which  sometimes 
lead  the  sufferer  to  recognize  his  own  malady.  As  they  are  con- 
veyed some  distance  from  the  site  of  the  narrowing,  they  have  only 
a  limited  value  in  localizing  its  position.  Over  a  distended  coil  of 
the  intestine,  which  affords  a  metallic  tone  by  percussion,  one  can  some- 
times hear  metalliclike  rustling  sounds,  or  they  can  be  produced  by 
blows  upon  that  portion  of  the  gut  with  the  finger  tips.  Friction 
sounds  like  the  rub  of  leather,  exactly  similar  to  the  pleuritic  friction 
sounds,  may  be  heard  with  the  stethoscope  when  there  is  a  dry  in- 
flammation of  the  serous  covering,  but  it  may  be  as  often  felt  as 
heard,  as  already  stated.  By  the  introduction  of  air  into  the  colon, 
which  can  be  readily  done  by  passing  in  a  soft  rectal  tube  and  forc- 
ing air  through  this  w^ith  a  double  syringe  bulb,  we  may  see  or  per- 
cuss the  whole  length  of  this  portion  of  the  intestine,  marking  out 
particularly  the  transverse  part.  This,  too,  will  often  aid  us  in  detect- 
ing and  locating  a  colon  stenosis,  provided  it  is  narrow  enough.  If, 
however,  it  is  large  enough  to  allow  air  to  pass  freely,  but  not  enough 
to  permit  the  passage  of  feces,  the  method  may  readily  lead  us  into 
error.  If  the  stenosis  is  very  narrow,  the  introduction  of  air  causes 
pain,  the  air  escapes  around  the  tube  in  the  anus,  and  a  stethoscope 
placed  over  the  lower  colon  will  disclose  a  long-drawn-out  sighing  tone 
as  the  air  passes  slowly  through  the  narrowing.  When  intestinal 
tumors  are  present,  inflation  also  aids  us  by  bringing  the  growth 


106  DISEASES   OF   THE   DIGESTIVE   TRACT 

nearer  the  palpating  finger,  provided  it  is  on  the  anterior  periphery 
of  the  gut ;  when,  on  the  contrary,  it  is  situated  at  the  mesenteric  at- 
tachment, the  mass  is  forced  away  from  the  surface,  tympanitic  reso- 
nance appears  above,  and  exactly  the  same  conditions  prevail  as  when 
a  renal  tumor  lies  behind  the  intestine.  The  use  of  the  gastrodia- 
phane,  which  has  an  electric  light  bulb  at  the  end  of  a  gastric  sound, 
by  which  the  contour  of  the  stomach  was  shown  on  the  abdominal 
wall  in  a  dark  room  when  the  light  was  turned  on,  now  possesses  only 
a  historical  interest,  since  x-ray  photography  has  been  employed  for 
delineation  of  the  stomach.  The  use  of  the  gastroscope,  based  on  in- 
struments of  a  like  nature,  by  which  a  direct  view  of  portions  of  the 
internal  surface  of  the  stomach  could  be  obtained,  has,  on  account  of 
the  danger  associated  with  its  use  been  largely  rejected. 

RADIOLOGICAL  EXAMINATION  OF  THE  TRACT. 

This  examination  is  to  be  employed  as  an  adjuvant  to  our  other 
means  of  examination.  When  we  first  found  we  could  watch  the 
action  of  the  stomach  by  giving  a  contrast  meal — consisting  of  40-60 
grams  of  bismuth  subcarbonate,  suspended  in  buttermilk,  or  other 
convenient  menstruum,  which  would  not  allow  rapid  deposition,  and 
with  the  use  of  the  fluoroscopic  screen  could  observe  every  motion 
of  the  organ,  or  at  any  moment,  by  means  of  a  radiograph,  fix  the 
form  and  position  of  the  stomach  or  intestine  on  a  plate — it  opened 
up  a  wide  field  for  increasing  our  knowledge  of  the  pathological 
conditions  of  that  organ.  As  with  all  other  new  methods,  the  medi- 
cal profession  expected  too  much  of  it,  hoping  that  at  last  we  had 
a  means  of  diagnosis  which  was  infallible,  and  patients  in  whose 
cases  not  the  slightest  efforts  were  made  to  reach  a  conclusion  as 
to  the  nature  of  the  illness,  other  than  ascertaining  the  history, 
were  sent  to  the  radiologist  for  diagnosis.  Under  these  unnatural 
demands,  x-ray  examinations  were  pronounced  worthless  by  some 
w^ho  had  been  disappointed  in  their  exaggerated  expectations.  At 
last  this  method  of  examination  has  reached  its  level  as  a  corre- 
lated part  of  the  different  means  of  investigation,  in  which  the 
amnesia  and  physical  and  chemical  examinations  are  included ;  in  fact, 
it  seems  to  us  that,  where  the  results  of  the  other  means  are  not  clear 
or  are  contradictory,  no  physician  has  done  his  duty  by  his  patient 
without  securing  some  good  radiograms  of  the  digestive  tract. 

The  Normal  Stomach. — The  normal  stomach,  to  which  reference 
has  already  been  made,  has  so  little  fixity  of  shape  that  but  scanty 


PHYSICAL.   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT       107 

importance  can  be  attached  to  inference  from  its  form.  To  its  con- 
tour, however,  much  significance  can  be  ascribed.  Fasting,  the  stom- 
ach forms  a  sheathlike  body,  whose  edges  are  folded  and  on  the  fold 
building  is  based  the  transverse  shortening  of  the  organ;  at  its  sum- 
mit, even  when  empty,  a  considerable  bubble  of  air  can  always  be 
found,  which  is  distinguished  by  its  peculiar  brightness,  as  compared 
with  surrounding  organs  as  well  as  with  the  remainder  of  the  viscus. 
The  form  of  this  is  usually  a  half-moon,  with  the  concavity  upward ; 
its  size  is  considerable,  and  even  in  the  fasting  stomach  it  increases 
as  food  is  taken  and  again  diminishes,  sometimes  disappearing  as  the 
contents  pass  through  the  pylorus.  In  atonic  stomachs  this  bubble 
impresses  one  by  its  size  and  persistence,  and  it  is  unusually  large  in 
the  aerophagists.  The  disappearance  of  these  folds,  as  the  stomach 
fills,  has  a  marked  diagnostic  importance,  and  is  completed  when  the 
zigzag  outlines  of  the  organ  assume  a  smooth  contour,  which  may 
be  accomplished  in  the  normal  individual  by  very  small  quantities 
— for  instance,  30  c.c.  have  been  found  sufficient  to  cause  the  oblitera- 
tion of  the  gastric  folds,  the  reason  for  which  being  the  tonicity  of 
the  musculature,  which  induces  the  organ  to  close  down  firmly  on 
its  contents.  This  is  called  the  peristole,  and  on  its  degree  we  may 
base  our  opinion  as  to  the  tonicity  of  the  stomach ;  when  this  is 
markedly  impaired,  we  find  on  taking  the  meal  that  the  long  axis  of 
the  organ  is  increased,  that  the  upper  level  of  the  content  does  not 
extend  as  liigh  as  customary,  and  that  an  additional  ingestion  of 
food  does  not  change  this  upper  limit.  The  increase  in  volume  is 
usually  in  a  transverse  direction.  In  hypersecretion  this  unfolding 
of  the  stomach  takes  place  much  more  rapidly,  while  in  achylia  it  is 
delayed.  Whenever,  too,  the  stomach  suffers  a  change  of  form  from 
the  scar  tissue  of  ulcer  or  malignant  disease,  again  the  disappearance 
of  the  folds  departs  far  from  the  normal,  and  these  changes  should 
be  observed  carefully,  since  valuable  conclusions  may  be  dra\Mi  as 
to  the  existence  of  these  two  diseases. 

The  contractions  of  the  stomach  are  not  visible  in  its  upper  part, 
but  about  the  beginning  of  the  middle  third  commence  as  shallow 
waves,  which  grow  deeper  and  deeper  until  at  the  pyloric  portion 
the  antrum  is  apparently  cut  off  completely  from  the  rest  of  the 
stomach.  Both  the  rapidity  and  depth  of  these  contractions  may 
vary,  and,  while  little  of  clinical  value  may  be  drawn  from  the  former 
fact,  variations  of  the  latter  have  been  found  fairly  constant  with 
certain  diseases.  For  instance,  the  contractions  are  much  deeper 
when  there  is  a  functional  or  organic  stenosis  at  the  pylorus  from 


108  DISEASES   OF   THE  DIGESTIVE   TRACT 

the  muscular  hypertrophy,  which  may  be  followed  in  a  longer  or 
shorter  time  by  shallow  waves,  which  are  interpreted  as  evidence 
of  muscle  exhaustion.  A  series  of  vigorous  contractions  means  a 
normal  tonus  of  the  organ,  while  shallow  waves  indicate  ectasia  or 
atony.  Still,  it  is  not  safe  to  put  too  much  dependence  on  the  de- 
gree of  the  contractions  on  account  of  the  marked  influence  of  the 
emotions  on  the  peristalsis;  this  is  equally  true  of  inference  as  to  the 
musculature  based  on  the  same  evidence,  but  the  contractions  may 
be  so  violent  that  the  lower  stomach  is  frequently  segmented  by  them, 
and  yet  there  may  be  no  organic  disease. 

In  health  the  pylorus  always  appears  as  a  clear  line  between  the 
dark  bulbous  duodenum  (sometimes  called  the  "bishop's  cap'')  and 
the  antrum,  both  filled  with  bismuth,  but  marked  changes  in  this  pic- 
ture occur  where  the  sphincter  is  involved  in  cicatricial  tissue  from 
ulcer  or  cancer,  or  is  fixed  by  adhesions. 

The  determination  of  the  motility  of  the  stomach  is  one  of  the 
greatest  aids  we  have  derived  from  radiology,  but,  to  be  of  value,  the 
conditions  must  not  be  made  too  hard  and  fast.  When,  with  a  stom- 
ach fasting,  one  gives  50  grams  of  bismuth  subcarbonate  and  350  c.c. 
of  buttermilk,  apart  from  a  very  small  remnant  which  may  remain  in 
the  stomach  for  hours,  the  organ  should  be  emptied  in  six  hours. 
When  at  this  period  one-half  of  the  original  meal  remains,  we  may 
conclude  that  there  is  functional  or  organic  stenosis  of  the  pylorus. 
Very  often,  too,  one  can  draw  certain  conclusions  from  the  picture 
presented  by  the  residue.  If  long  transversely  and  half-moon  shape, 
it  suggests  a  decompensated  gastric  hypertrophy  due  to  stenosis;  a 
moderate  residue,  lying  to  the  left  of  the  median  line,  with  the 
greater  curvature  arising  almost  perpendicularly,  means  an  ulcer  of 
the  lesser  curvature,  while  a  similar  remnant,  with  a  zigzag  right 
edge,  causes  a  marked  suspicion  of  cancer  of  the  pylorus.  Between 
the  x-ray  residue  and  microscopic  retention,  as  determined  by  wash- 
ing out  the  fasting  stomach,  a  parallel  usually  exists,  but  occasionally 
it  is  found  that  the  bismuth  meal  leaves  the  stomach  promptly,  while 
remnants  can  be  washed  out  after  the  usual  eight-hour  interval. 
Huerter's  explanation  of  this  is  that  spasm  induced  by  hyperacid 
contents  is  a  partial  cause  for  this  retention,  which  is,  of  course, 
relieved  by  the  bismuth's  power  of  neutralization.  Again,  the  x-ray 
may  show  moderate  retention,  while  washing  brings  to  light  no  frag- 
ments; this,  according  to  Dodds,  depends  on  the  inability  to  direct 
a  soft  tube  to  the  most  dependent  part  of  the  stomach,  so  that  the 
water  introduced  does  not  disturb  the  small  pool  of  residue  and  comes 


PHYSICALi   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE  TRACT       109 

back  clear.  In  this  respect,  then,  the  new  method  cannot  replace 
the  old  and  both  should  be  employed,  and  operation,  too,  can  de- 
termine which  is  to  have  the  most  successes  to  its  credit. 

By  no  other  means  have  we  been  able  to  determine  the  size  and 
position  of  the  stomach  with  exactness  as  we  have  by  rontgenology. 
The  lower  border  of  the  stomach  in  the  radiogram  should,  if  normal, 
be  at  the  level  of  the  navel,  and,  while  the  latter  point  in  the  obese 
and  in  othg:'s  is  a  variable  one,  all  efforts  to  replace  it  have  failed. 
In  a  radiogram  where  the  navel  has  not  been  marked,  the  body  of  the 
fourth  lumbar  vertebra  should  be  selected  as  the  point  with  which 
the  normal  lower  border  should  correspond.  A  true  ptosis  of  the 
stomach,  in  its  acquired  or  congenital  form,  comprises  a  lengthen- 
ing of  the  longitudinal  axis,  with  lowering  of  the  pylorus  and  dis- 
placement to  the  left.  It  lies  as  a  long  tube,  with  parallel  sides  to 
the  left  of  the  vertebrae,  while  the  lower  border  is  found  far  below  the 
iliac  crest.  While  the  picture  of  the  acquired  gastroptosis,  due  to 
rapid  emaciation  or  childbearing,  is  much  the  same  in  many  respects, 
there  is  this  difference,  that,  due  to  accompanying  atony  in  the  latter, 
the  bismuth  meal  fills  it  to  about  one-half  of  its  capacity,  and  above 
this  the  air  bubble  forms  an  inverted  wedge.  The  lower  portion  of 
the  stomach  is  enlarged,  while,  in  accordance  with  its  extent,  the 
pylorus  assumes  a  position  lower  down  and  to  the  left  of  its  normal 
site,  and  is  freely  movable.  Another  characteristic  feature  of  the 
ptosed  and  atonic  stomach  in  the  radiogram  is  the  narrowing  found 
at  its  center,  which  is  not  spastic  and  should  never  be  taken  for 
an  organic  constriction.  While  the  time  of  emptying  may  be  normal, 
it  is  usually  somewhat  prolonged,  and.  if  dilatation  is  added  to  mis- 
placement and  atony,  it  is  distinctly  prolonged.  Extensive  dilata- 
tion from  stenosis  can  be  distinguished  in  a  radiographic  examination 
from  the  enormous  distance  between  the  bubble  and  the  bismuth, 
which  assumes  naturally  the  lowest  section  of  the  stomach,  while, 
owing  to  a  lack  of  peristole,  the  lateral  contours  of  the  stomach  are 
not  well  defined.  An  absolute  proof  of  dilatation  due  to  organic 
stenosis  is  the  finding  of  any  considerable  residue  in  the  stomach 
twenty-four  hours  after  the  meal.  Beginning  decompensation  dift'ers 
from  this  picture  in  that  the  contractions  begin  much  above  the  mid- 
dle third,  as  is  usual,  and  produce  deeper  waves,  which  may  lead  to 
gross  segmentation  of  the  organ ;  then  the  waves  become  shallower, 
and,  unless  the  compensation  of  the  stenosis  is  nearly  at  par,  there 
will  occur  a  complete  cessation  of  peristalsis  for  a  time.  Therefore 
the  violent  contractions  alone,  on  account  of  psychic  influence,  can- 


110  DISEASES   OP   THE   DIGESTIVE   TRACT 

not  be  interpreted  absolutely  as  a  sign  of  stenosis,  but  those  followed 
by  quiescence  can  be  so  regarded.  Radiology  has  also  shown  us  that 
gastric  spasm  may  exist,  accompanied  by  pain,  without  any  local  cause 
for  it.  These  spasms,  though  cojifined  to  the  lower  two-thirds  of  the 
stomach,  may  produce  the  most  unusual  shapes — semblance  of  the 
hourglass  stomach,  temporary  obliteration  of  the  pyloric  portion,  or 
such  a  picture  as  is  seen  in  an  interstitial  contraction  (linitis  plastica) 
of  the  whole  organ.  In  addition  to  the  above  more  general  and  ex- 
tensive spasm,  we  may  have  a  tetanic  contraction  of  a  certain  group 
of  circular  muscles,  which  produces  a  radiogram  precisely  similar  to 
that  of  true  hourglass  stomach,  which  is  often  called  the  ''pseudo" 
form.  Not  alone  this  spasm,  but  tumors  of  adjacent  organs — like  the 
spleen,  kidney,  liver,  and  pancreas,  or  retroperitoneal  glands  when 
enlarged — may  so  press  on  the  stomach  as  to  give  this  impression  of 
a  division  into  two  parts.  Naturally,  from  a  therapeutic  standpoint, 
it  is  very  essential  to  distinguish  the  spasmodic  variety  from  the  true, 
produced  by  contraction  of  scar  tissue  from  an  old  ulcer.  The  most 
valuable  answer  to  this  question  is  whether  this  division  is  per- 
manent or  variable,  though  a  spasmodic  contraction  may  remain  pretty 
constant,  even  when  due  to  an  ulcer  at  the  side,  which  does  not 
produce  a  narrowing  by  scar  tissue.  Then,  too,  in  the  spasmodic 
form  the  lower  section  is  promptly  filled  by  the  contrast  meal,  which 
is  not  true  with  the  organic  form. 

Gastric  Ulcers. — Gastric  ulcers,  unless  they  have  produced  narrow- 
ings,  are  very  difficult  to  detect  by  the  x-ray  examination,  and  the 
newer  method  has  helped  us  but  little  in  diagnosis.  Whether  situated 
on  the  anterior  or  posterior  surface  of  the  stomach,  the  bismuth  meal 
obscures  them  fully.  Ulcers  in  the  pylorus  are  no  easier  to  detect 
because  the  spasm  of  the  long  muscles  prevents  the  depression  from 
filling.  "When  much  scar  tissue,  however,  has  formed  and  the  edges 
are  firm  and  rigid,  there  is  a  distinct  difference.  After  the  bismuth 
meal  is  taken,  these  appear  as  projections  on  the  surface  or  contour 
of  the  picture  if  situated  on  the  anterior  wall ;  on  the  posterior  and 
in  the  pylorus  but  little  hope  is  offered  for  their  detection,  but  this 
diverticulum  projection  of  the  stomach  usually  disappears  as  the 
latter  empties,  and  in  only  the  rarest  cases  does  it  persist.  The  open- 
ing or  crater  of  such  an  ulcer  is  always  filled  with  bismuth,  and  only 
in  penetrating  ulcers  is  a  bubble  in  its  upper  section  visible.  When 
such  an  ulcer  produces  adherence  to  a  neighboring  organ — the  liver 
or  pancreas — then  the  gastric  juice  digests  away  a  portion  of  it,  mak- 
ing a  considerable  cavitv,  which  contains  bismuth  and  an  air  bubble 


PHYSICAL   METHODS   OB^   EXAMINATION   OP   THE   DIGESTIVE   TRACT        111 

above,  connected  with  the  stomach  by  a  narrow  canal,  discernible  be- 
cause it  also  contains  contrast  material.  These  penetrating  ulcers 
are  also  to  be  distinguished  from  cancer  because  they  always  add  to 
the  contour  of  the  stomach  and  never  take  away  any  portion,  as  the 
latter  does.  On  account  of  the  narrow  communication,  this  may  fail 
to  be  portrayed  by  the  picture,  and  then  we  have  a  failure  of  the 
cavity  to  empty  when  the  stomach  does,  so  that  it  looks  like  an  ex- 
crescence on  the  finely  discernible  contour.  By  means  of  the  irrita- 
tion of  the  nerve  endings,  which  are  laid  bare  by  the  ulcer,  we  may 
have  spasm  of  circular  or  longitudinal  muscles,  with  corresponding 
distortions  in  the  figure  of  the  stomach.  The  former  gives  us  the 
appearance  of  the  spasmodic  hourglass  stomach,  whether  fresh  or 
chronic,  in  which  the  nerve  terminals  are  inclosed  in  the  scar  tis- 
sue. As  stated,  purely  psychic  influences  may  produce  these  deep 
segmentations  of  the  stomach,  so  that,  if  they  are  to  be  of  any  value 
for  the  diagnosis  of  ulcer,  they  must  be  constant  and  always  at  the 
same  point  in  the  subsequent  pictures.  When  the  longitudinal  muscles 
are  incited  by  an  ulcer,  then  there  is  a  rolling  up  of  the  pyloric  por- 
tion, compared  to  the  appearance  of  a  snail ;  by  this  spasm  the  pyloric 
portion  and  the  pylorus  itself  are  found  to  the  left  of  the  median 
line.  Sometimes  the  spasm  becomes  so  great  that  the  ascending  por- 
tion of  the  stomach  and  the  pylorus  appear  so  adherent  that  the  divid- 
ing line  between  cannot  be  ascertained.  These  conditions  are  typical, 
but  not  at  all  constant,  so  that,  by  radiology,  peptic  ulcer — unless  at 
the  pylorus  and  accompanied  by  stenosis — is  one  of  the  most  difficult 
lesions  to  discover.  It  is  much  different,  however,  with  gastric  can- 
cer, and,  as  the  ophthalmologist  may  often  diagnose  a  probable  ne- 
phritis before  other  clinical  means  of  examination  show  it,  so  the  radiol- 
ogist may  often  detect  a  cancer  when  only  vague  symptoms  and  no 
marked  loss  of  gastric  functions  are  present. 

Cancer  of  the  Stomach, — This  has  the  peculiarity  of  growing  into 
the  lumen  of  the  organ,  leaving  in  its  radiogram  a  defect  in  the 
contour,  which  may  vary  as  to  site,  form,  and  extent,  corresponding 
with  the  growth.  Furthermore,  the  defective  periphery  may  be  zig- 
zag or  have  a  moth-eaten  appearance,  characteristics  which  so  differ- 
entiate such  outlines  from  the  clear-cut  contour  of  the  normal  stom- 
ach that  diagnosis  of  cancer  from  the  radiogram  presents,  perhaps, 
as  little  difficulty  as  any  when  visible.  Then,  again,  the  scirrhous 
form — the  most  common — produces  marked  distortion  in  the  shape 
of  the  stomach,  usually  in  the  direction  of  distinct  diminution  in  its 
size,  and  at  the  same  time  marked  insufficiency  of  the  pylorus  is  pres- 


112 


DISEASES   OF   THE   DIGESTIVE   TRACT 


ent.  Two  other  characteristics  of  this  condition,  either  under  the 
screen  or  in  the  picture,  are  the  loss  of  peristalsis  and,  where  the  py- 
lorus does  not  functionate,  a  backing  up  of  the  food  in  the  esophagus, 
which  has  led  in  one  case  under  my  observation  to  a  radiological 
diagnosis  of  cancer  of  the  esophagus,  while  the  introduction  of  the 
tube  and  the  palpation  of  the  mass  showed  the  tumor  to  be  at  the 


Fig.  17. — Gastric  cancer.      (From  collection  of  Dr.  Arinl  W.  George.) 

pylorus.  Ordinarily,  the  growths  situated  at  the  pylorus  can  be 
most  easily  portrayed.  When,  however,  they  are  located  on  the  an- 
terior or  posterior  wall,  the  contrast  meal  may  obscure  them,  unless 
pressure  is  made  on  the  stomach,  when  the  regular  outline  is  brought 
out.  In  a  normal  stomach  the  pressure  of  the  finger  tip  produces  only 
a  rounded  clear  spot  on  the  periphery.  The  new  growths  at  the  car- 
diac portion  of  the  stomach  are  very  difficult  to  detect  with  the  x-ray 


PHYSICAL   METHODS   OF    EXAMINATION    OF    THE   DIGESTIVE   TRACT        113 

because  the  contrast  meal  does  not  fill  this  part  with  the  patient  in 
the  erect  position.  Still,  there  are  often  changes  in  the  contour  of 
the  air  bubble,  in  the  middle  of  which  the  growth  is  usually  situated, 
which  indicate  its  presence ;  these  changes  are  exaggerated  by  dis- 
tending the  stomach  with  air  and  by  examining  the  patient  in  a  prone 
position.  In  a  matter  as  important  as  this  the  question  will  often 
arise,  is  rontgenology  infallible  ?  Confession  must  be  made  that  other 
causes  may  produce  these  defects  in  the  filling  of  the  stomach  which 
are  interpreted  as  cancer,  such  as  (to  mention  a  few)  retroperitoneal 
masses  of  enlarged  glands  when  the  growth  is  in  an  adjacent  organ; 
cancer  of  the  choledochus,  primary  or  secondary ;  a  pancreatic  growth, 
which  compresses  the  pylorus  without  its  involvement — as  in  a  case 
of  my  own ;  a  mass  of  inflammatory  tissue  from  a  cholelithiasis  may 
give  the  appearance  of  a  prepyloric  cancer,  perigastric  adhesions, 
and,  rarely,  varices,  which  have  produced  pictures  mistaken  for  those 
of  gastric  cancer.  Another  vast  advantage  of  the  radiogram  is  that 
it  will  enable  us  to  find  tumors  in  locations  absolutely  forbidden  to 
palpation,  as  in  portions  of  the  fundus  where  the  ribs  interfere  or 
under  the  liver.  It  is  true,  they  often  descend  when  advanced,  so 
that  they  are  palpable,  but  that  is  an  event  occurring  often  too  late 
to  enable  us  to  offer  any  aid  to  the  patient.  Two  questions  we  should 
be  pleased  to  have  radiology  answer  for  us,  but  so  far  it  has  failed: 
is  a  pyloric  tumor  benign  or  malignant  and  are  there  metastases  ?  In 
regard  to  the  former  point,  some  aid  is  offered  by  the  size  of  the  stom- 
ach, which  often  becomes  enormous  from  the  dilatation  of  an  ulcer 
stenosis,  but  rarely  enlarged  to  any  great  extent  from  primary  can- 
cer; it  may  be  already  dilated  when  cancer  follows  ulcer.  The  radio- 
gram has  been  of  greatest  aid  to  us  in  demonstrating  just  what  hap- 
pens after  gastroenterostomy.  This  question  comes  up  frequently 
when  symptoms  occur  after  such  an  operation :  has  the  pylorus  be- 
come patent  and  the  new  orifice  closed,  or  does  there  exist  a  "vicious 
circle,"  as  it  is  called,  by  reflux  of  food  through  the  new  opening  and 
has  its  departure  by  the  pylorus  taken  place  ?  Now,  a  good  function- 
ing gastric  fistula  can  always  be  recognized  in  a  radiogram  as  a 
projection  from  its  lower  border,  which  is  in  reality  the  first  filled 
section  of  the  intestine;  this  projection  can  depart  in  its  full  width 
from  the  stomach  or  show  a  constriction  just  as  it  nears  the  stomach 
wall,  and  is  usually  found  to  the  extreme  left.  After  the  bismuth  is 
taken,  one  must  wait  some  time  before  the  segment  of  intestine  is 
visible,  showing  that  the  stomach  can  be  filled  as  well  as  the  normal 
one.     Apparently,  too,  the  food  escapes  at  intervals  exactly  as  it  does 


114  DISEASES   OF   THE   DIGESTIVE   TRACT 

through  the  pylorus,  though  no  valve  action  can  be  present.  All  ex- 
planations of  a  fold  of  intestine  producing  valve  action  are  based 
only  on  theory;  of  the  other  numerous  explanations  offered  for  this 
procedure,  none  have  any  clinical  value  and  may  be  omitted.  An 
interesting  fact,  however,  is  that,  when  no  food  can  be  seen  to  pass 
through  the  artificial  orifice,  but  all  goes  through  the  reopened  pylorus, 
laparotomy,  for  some  other  purpose,  has  shown  that  the  gastroenter- 
ostomic  fistula  is  fully  open.  In  our  experience  it  has  occurred  that 
a  new  growth  has  closed  the  artificial  opening,  and  ulceration  around 
the  pylorus  has  freed  it  from  obstruction.  It  has  been  further  es- 
tablished that,  when  marked  ectasia  of  the  stomach  from  stenosis  ex- 
ists, gastroenterostomy  relieves  the  stasis,  but  does  not  improve  the 
gastric  tonus.  When  the  pylorus  is  removed  or  artificially  closed, 
the  emptying  of  the  stomach  is  not  markedly  changed  from  that  ac- 
companying the  simple  gastroenterostomy,  and,  even  when  the  anas- 
tomosis is  not  made  at  the  most  dependent  portion  of  the  stomach, 
the  latter  is  equally  as  well  able  to  free  itself  from  the  food  which 
lies  below  the  level  of  the  orifice. 

The  Intestine. — The  intestine  is  made  visible  by  means  of  the  x-ray 
examination,  either  after  ingestion  of  the  contrast  (bismuth  contain- 
ing) meal,  or,  for  the  lower  stretches,  an  enema  of  the  same  substance 
may  be  used  with  better  results.  To  begin  with  its  first  portion  (the 
duodenum),  we  may  say  that  only  the  bulbous  portion — or  bishop's 
cap,  as  it  is  termed — is  distinctly  visible;  from  this  point  on — as  a 
result  of  the  periodic  discharges  from  the  stomach  and  the  marked 
dilution  produced  by  the  fluid  entering  the  intestine — apart  from  the 
faintest  shadows,  which  are  readily  overlooked,  no  accumulation  of 
bismuth  again  occurs  that  enables  the  tract  to  be  distinctly  seen  until 
we  reach  the  lowest  part  of  the  ileum.  In  between,  occasional  small 
segments  are  visible,  but,  on  account  of  the  many  lines  and  levels, 
it  is  impossible  to  construct,  even  in  the  mind's  eye,  the  ramifications 
of  the  continuous  intestine. 

For  the  portrayal  of  the  colon  a  period  of  twenty  hours  after  the 
bismuth  is  taken  by  mouth,  or  directly  after  an  enema,  is  chosen, 
when,  in  the  latter  case,  the  lower  ileum  may  be  found  filled,  but  in 
the  former  the  descending  colon  and  sigmoid  may  be  discerned  empty, 
and  a  later  period  must  be  selected,  dependent  on  the  motility.  In 
the  radiogram  of  the  colon  the  most  suggestive  feature  is  the  segmen- 
tation or  haustra,  which  may  be  so  deep  that  they  suggest  complete 
separation  of  the  fecal  portions.  This  appearance  is  most  marked 
after  ingestion  and  less  so  after  an  enema,  but  even  then  they  are 


PHYSICAL   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT        115 

distinctly  present  in  constipation,  accompanied  by  spasm.  The  cecum 
shows  but  little  of  this  segmentation,  and  is  not  well  separated  in 
the  picture  from  the  ascending  colon,  but  the  entrance  into  it  of  the 


Fig.  18. — Normal  bulbous  duodenum  (bishop's  cap). 

George.) 


(From  collection  of  Dr.  Arial  W. 


ileum  is  usually  well  marked.  The  appendix  is  often  visible,  whether 
bismuth  is  taken  by  the  mouth  or  rectum,  and  remains  filled,  for 
days  sometimes,  after  the  rest  of  the  tract  is  free  from  the  contrast 
material.     Radiology  is,  of  course,  our  best  means  of  studying  the 


116  DISEASES   OP   THE   DIGESTIVE   TRACT 

motility  of  the  intestine,  yet  no  fast  and  fixed  rules  have  been  estab- 
lished with  which  to  compare  abnormal  results.  Not  every  unusual 
delay  at  the  ileocecal  valve — ileal  stasis,  so  termed — means  bands  or 
membranes,  nor  does  a  forty-eight-hour  detention  of  bismuth  in  the 
colon  denote  a  marked  loss  of  tone.  The  determination  of  position 
by  this  means  has  been  particularly  valuable  in  the  detection  of  con- 
genital misplacements,  especially  in  the  redundant  sigmoid,  caus- 
ing great  accumulations  of  feces  or  Hirshsprung 's  disease.  Partic- 
ularly valuable  is  the  radiogram  in  detecting  the  marked  congenital 
looping  and  displacement  of  the  hepatic  flexure  of  the  colon,  and, 
together  ^\^th  the  screen  and  palpation,  in  excluding  adhesions  of  two 
adjacent  portions  whose  shadows  so  overlap  that  they  appear- as  one. 
As  a  means,  too,  of  explaining  many  obscure  forms  of  functional  con- 
stipation, radiology  has  played  an  important  part,  and  has  enabled 
us  to  determine  whether  the  delay  is  in  the  cecum  and  ascending 
colon,  due,  as  Faulhaber  believes,  to  an  early  solidification  of  the  fecal 
matter;  or  in  the  descending  colon,  due  to  spasm,  which  is  particu- 
larly prominent  in  the  sigmoid;  or  in  the  rectum,  either  from  weak- 
ness of  the  defecating  muscles  or  unusual  drying  out  of  the  fecal 
matter. 

Ulcerations  of  the  intestines  have  also  shown  the  value  of  radiology 
in  their  detection,  but  such  successes  are  rare  and  not  to  be  expected. 
The  successful  radiograms  of  duodenal  ulcer  show  the  projections 
with  the  combined  bismuth  and  air  content,  but  many  an  ulceration 
of  this  character  exists  where  no  characteristic  feature  can  be  ob- 
tained. Indirectly,  however,  in  the  rapid  emptying  of  the  stomach 
we  have  a  proof  of  the  greatest  importance.  Furthermore,  the  ulcer 
scar  may  cause  spasm  of  the  first  portion  of  the  duodenum,  readily 
visible  when  some  distance  from  the  pylorus,  but,  as  over  60  per  cent 
of  such  ulcers  are  within  a  centimeter  from  this  point,  it  is  rarely 
available  for  diagnosis.  When  the  pylorus  is  held  firmly  to  the  right 
of  the  median  line  and  does  not  recede  on  emptying  of  the  stomach, 
we  have  proof  of  adhesions,  which  may  be  equally  as  well  the  result 
of  duodenal  ulcer  or  cholecystitis.  The  ulceration  of  the  cecum,  so 
common  in  tuberculosis  and  malignant  diseases  without  stricture, 
furnishes  a  characteristic  picture  of  the  intestine,  which  shows  this 
part  and  the  greater  portion  of  the  ascending  colon  obliterated.  This 
may  be  explained  by  the  superficial  ulceration,  causing  such  an  ex- 
aggerated peristalsis  that  no  considerable  amount  of  bismuth  can  re- 
main there,  and  operation  has  confirmed  so  many  of  these  findings 
that  there  can  be  no  doubt  of  its  accuracy. 


PHYSICAL.  METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT       117 

The  stenoses  of  the  intestine,  whether  due  to  circular  contraction 
from  malignant  disease  or  from  scar  tissue  following  ulcer,  or  to 
external  compression  from  incarceration  or  compression  by  bands, 
are  readily  detected  by  the  x-ray.  Again,  one  must  be  warned  against 
accepting  mere  constriction  as  proof  of  this,  and  demand  must  be 
made  for  a  radiogram  showing  a  considerable  stretch  of  intestine  be- 
yond the  narrowing,  either  empty  or  very  scantily  filled.  The  de- 
tection of  stenosis  of  the  small  intestine,  other  than  the  lower  ileum, 
is  very  difficult  because  of  the  normal  lack  of  continuity  of  the  bis- 
muth column,  but  in  the  colon,  when  the  contrast  material  is  given 
by  enema — when,  of  course,  the  obliterated  portion  lies  in  the  op- 
posite direction  with  reference  to  the  narrowing — such  pictures  are 
very  satisfactory,  indicating  closely  the  site,  and  at  operation  prevent 
undue  handling  of  the  intestine.  When  a  constriction  is  chronic,  it 
is  much  more  advisable  to  combine  the  two  methods  of  oral  and  rectal 
administration.  Furthermore,  one  should  always  demand  that  the 
intestine  be  emptied  by  preliminary  laxative  or  by  cleansing  enema, 
and  that  the  stricture  be  constant  in  a  subsequent  examination  after 
a  few  days.  It  has  been  shown  also  that  it  does  not  require  a  very 
marked  narrowing  to  prevent  the  advance  of  the  bismuth  enema. 
Again,  after  a  relatively  short  delay  it  is  sometimes  found  that,  where 
the  passage  is  not  too  narrow,  the  bismuth  may  continue  its  course, 
filling  the  portion  beyond  not  as  fully  as  that  before,  but  the  margin 
is  so  small  that  much  judgment  must  be  employed  to  properly  in- 
terpret the  findings.  A  repeated  examination  is  much  better  where, 
in  case  of  true  stenosis,  the  same  features  are  found. 

AYlien  cancer  of  the  colon  is  present  with  stenosis,  the  ingestion  of 
the  bismuth  does  not  offer  as  good  an  opportunity  for  a  character- 
istic radiogram  as  does  the  enema.  If  the  growth  is  in  the  transverse 
or  descending  colon,  or  there  is  failure  of  the  dilatation  before  the 
stricture,  as  occurs  where  the  feces  are  liquid,  though  there  is  delay 
at  the  constriction,  the  feces  reform  beyond.  There  will  naturally 
be  at  this  point  an  hiatus  in  the  continuous  shadow  of  the  colon,  but 
little  dependence  can  be  placed  on  this  alone,  for  it  has  been  known 
to  occur  in  a  perfectly  normal  intestine.  "When,  however,  the  stenosis 
is  fairly  narrow,  and  there  is  found  an  enormous  dilatation  before  it, 
represented  in  the  picture,  there  is  barely  a  ribbonlike  trace  beyond 
it.  the  bismuth  is  retained  for  days,  the  feces  are  fluid,  and,  because 
of  the  difficulty  which  gas  finds  in  making  its  way  through  a  stenosis 
with  liquid  feces,  the  upper  portion  of  the  colon  will  be  found  free 
from  the  contrast  material,  similar  to  the  air  bubble  of  the  stomach. 


118 


DISEASES   OF    THE   DIGESTIVE    TRACT 


The  dividing  line  between  these  two  will  always  be  found  horizontal. 
The  appearance  of  cancer  of  the  cecum  with  stricture  does  not  differ 
from  that  of  tuberculous  ulceration,  mentioned  above,  twenty-four 
hours  after  ingestion.  The  whole  middle  abdomen  is  filled  with  de- 
tached fragments  of  bismuth  shadow,  many  with  the  air  bubble  above 


Fig.  19. — Carcinoma  of  the  cecum  with  stenosis.      (From  collection  of  Dr.  Arial  W.  George.) 

and  with  a  horizontal  line  of  demarcation.  The  cecum  and  colon  are 
blotted  out  of  the  picture  when  the  contrast  is  given  by  mouth,  and 
a  similar  appearance  is  found  in  stricture  of  the  small  intestine,  only, 
of  course,  when  the  bismuth  is  taken  by  the  mouth. 

The  contrast  material  has  been  known  to  remain  in  the  intestine  as 
long  as  seventy-nine  hours.     These  .gas  bubbles,  with  their  contrast 


PHYSICAL   METHODS   OF   EXAMINATION    OF    THE   DIGESTIVE   TRACT        119 

material  base,  are  found  at  the  turns  of  the  small  intestine,  varying 
in  size,  and  are  most  characteristic,  because,  no  matter  how  great  the 
accumulation  of  gas  in  the  intestine  may  be,  they  never  form  except 
when  there  is  stenosis.     Whuen  in  chronic  stenosis  of  the  small  in- 


Fig.  20. — Cancer  of  the  rectum,  bismuth  ingested.      (From  collection  of  Dr.  Arial  W.  George.) 


testine  much  intermittent  rigidity  occurs  above,  this  picture  is  largely 
modified,  for  both  gas  bubbles  and  horizontal  surface  may  disappear 
during  the  contraction.  Diagnosis  between  the  large  and  small  in- 
testine is  usually  not  difficult,  because  in  the  former  the  degree  of 
dilatation  is  much  greater  than  could  probably  be  found  in  the  latter ; 


120  DISEASES   OF   THE   DIGESTIVE   TRxVCT 

still,  in  the  latter  the  haustra  persist,  though  markedly  less  distiD''+. 
Then,  again,  in  the  colon  only  one  or  possibly  two  levels  (divic!:n„ 
line  between  gas  and  contrast  material)  will  be  found,  while  in  tiie 
small  intestine,  on  account  of  its  ramifications,  many  such  levels  are 


Fig.  21. — Adhesions  of  parts  of  the  colon.      (From  collection  of  Dr.  Arial  W.  George.) 

present.     When  the  ileocecal  valve  is  forced  by  the  stagnating  con- 
tents from  a  colon  stricture,  then  this  deduction  would  be  worthless, 
but  in  any  case  of  doubt  a  contrast  enema  would  settle  the  question. 
A   stenosis   of  the  duodenum   at   considerable   distance   from  the 


PHYSICAL   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT        121 

'^^'oriis  gives  a  very  characteristic  appearance  of  distended  intestine, 
^.v/xxJra^st  material,  and  air  bubble,  because,  as  stated,  outside  of  the 
bulbous  portion,  the  duodenum  is  not  discernible  by  the  x-ray  under 
normal  circumstances.  Under  the  screen,  too,  can  be  watched  the 
violent  peristaltic  waves  which  drive  the  intestinal  contents  to  a 
certain  point,  but  cannot  force  them  beyond  it.  As  already  stated,  a 
radiogram  can  inform  us  that  a  stricture  exists,  but  can  tell  us  noth- 
ing as  to  its  character,  whether  malignant  or  not,  as  it  can  in  the 
stomach.  Furthermore,  radiology  can  offer  us  no  aid  in  the  diagnosis 
of  cancer  of  the  intestine  where  no  stricture  is  present.  The  radio- 
gram is  equally  of  aid  in  determining  the  presence  of  rectal  cancer 
when  it  cannot  be  reached  by  the  finger  and  a  rectoscope  is  not  avail- 
able, and  equally  as  advantageous  in  determining  its  extent  when 
that  instrument  can  not  be  introduced  on  account  of  the  narrowness 
of  the  opening. 

Adhesions  and  unusual  mobility  of  certain  sections  of  the  intestine 
can  often  be  made  out  by  the  x-ray,  except  in  the  first  portion  of  the 
duodenum,  which  escapes  on  account  of  its  protected  position  under 
the  liver.  These  adhesions  are  most  readily  detected  in  the  colon, 
which  under  the  palpating  hand  behind  the  screen,  if  normal,  can 
be  moved  about  freely  in  all  directions,  particularly  the  transverse 
portion.  If  the  colon  is  apparently  attached  to  an  internal  body, 
like  the  liver,  or  to  the  abdominal  wall,  an  attempt  to  move  it  will 
be  found  impossible ;  if  attached  to  a  movable  body,  like  the  stomach, 
or  to  another  section  of  itself,  an  attempt  to  place  the  hand  vertically 
on  the  abdomen  and  to  press  down,  so  that  it  shall  separate  the 
shadows  of  the  tw^o  organs  or  parts  of  the  same  organ,  it  will  succeed, 
except  where  an  adhesion  is  present.  Then,  too,  the  radiogram  is 
most  useful  in  showing  displacements  of  the  colon  due  to  abscesses 
and  tumors.  Such  transpositions  are  often  the  result  of  hydro- 
nephrotic  tumors,  which  press  the  ascending  and  descending  colons 
toward  the  median  line,  as  do  psoas  and  iliac  abscesses. 

RESULTS  OF  THE  X-RAY  EXAMINATIONS. 

Perhaps,  in  closing,  a  short  critical  resume  of  the  practical  or 
clinical  results  of  the  x-ray  examinations  of  the  tract  will  not  be  out 
of  place.  Some  of  the  most  hopeful  expectations  expressed  in 
previous  sentences  have  met  with  disappointment,  while  others  have 
become  firmly  grounded  by  our  subsequent  experience. 

Esophagus. — Probably  in  no  field  of  examination  have  these  means 


122  DISEASES   OF   THE   DIGESTIVE   TRACT 

proved  more  valuable  than  in  the  diseases  of  the  esophagus,  partic- 
ularly in  carcinoma  of  that  organ.  In  96  per  cent  of  all  cases  we 
can,  however,  usually  determine  such  diseases  by  the  use  of  the 
stomach  tube  and  by  the  history.  On  the  contrary,  there  are  those 
cases  where,  when  the  tube  meets  with  no  obstruction,  though  car- 
cinoma exists,  we  can  learn  of  its  presence  only  by  means  of  the 
rontgenograph  through  a  more  or  less  persistence  or  stagnation  of  the 
bismuth  in  the  esophagus.  Even  the  smallest  remnants  are  significant 
of  an  obstruction  in  this  canal,  and  this  latter,  together  with  other 
symptoms  of  stenosis,  leads  to  a  suspicion  of  carcinoma. 

In  still  greater  degree  can  this  delay  in  the  passage  of  the  bismuth 
into  the  stomach  be  utilized  for  carcinoma  of  the  cardia.  Here  the 
doubtful  cases  are  much  more  numerous  than  where  the  growth  is 
situated  in  the  esophagus,  since  in  the  latter  cases,  difficulty  in  deg- 
lutition and  inability  to  pass  the  tube  are  lacking.  One  can  often 
observe,  under  the  screen,  a  delay  in  the  passage  of  the  bismuth, 
while  the  under  portion  of  the  esophagus  forms  a  sausage-  or  funnel- 
like image.  Furthermore,  since  in  such  eases,  when  the  organic 
stenosis  is  at  the  cardia,  the  esophagus  shows  a  more  extensive  amount 
of  atony,  the  latter  often  appears,  in  its  entirety,  somewhat  enlarged. 
Still,  oftener  the  detection  of  the  benign  disease  of  the  esophagus, 
especially  spasm,  comes  from  the  rontgenographic  examination.  Very 
often  we  find  patients  who  complain  of  a  sensation  of  constriction  of 
the  esophagus,  with  pressure  following.  A  soft  sound  passes  readily, 
and  the  delayed  passage  of  the  bismuth  can  be  detected  only  under  the 
screen,  and  sometimes  by  means  of  the  rontgenograph.  The  screen 
forms  the  more  valuable  means  of  examination  under  these  circum- 
stances, because  often  the  spasm  can  be  seen  to  relax  and  the  bismuth 
passes  readily  into  the  stomach. 

]\Iore  often  do  we  find,  as  a  result  of  chronic  cardiospasm,  the  evi- 
dences of  a  dilatation  or  a  diverticulum  of  the  esophagus.  Such 
pouches,  as  is  well  known,  will  sometimes  contain  as  much  as  three- 
fourths  of  a  liter  of  fluid.  Under  the  x-ray  examination  they  appear; 
in  all  their  outline  and  entirety,  and  with  such  accuracy  as  cannot 
be  determined  by  any  other  means  of  diagnosis. 

Stomach. — Ulcer  of  the  stomach  has  not  proved  amenable  to  de- 
tection by  x-ray  examination,  except  when  perforation  or  marked 
obstruction  have  been  produced. 

Two  features  of  the  ulcer,  however,  have  been  fairly  well  estab- 
lished in  the  rontgenographic  examination — first,  the  spastic  contrac- 
tion of  the  greater  curvature,  and,  second,  the  delayed  emptying  of 


PHYSICAL   METHODS  OP   EXAMINATION   OP   THE   DIGESTIVE   TRACT        123 

the  stomach.  The  former,  however,  unfortunately  is  not  always  con- 
stant, and  it  must  be  repeatedly  found  at  exactly  the  same  point  to 
make  it  reliable.  In  several  cases  which  have  been  operated  under 
my  advice,  nothing  was  discovered  by  the  rontgenologist,  while  the 
surgeon  readily  detected  scar  tissue  at  the  lesser  curvature,  indicating 
an  old  ulcer.  Then,  as  previously  mentioned,  we  must  also  recognize 
that  such  contractions  may  arise  from  purely  nervous  influences. 
Then,  too,  this  contraction  can  have  another  clinical  value,  such  as 
pointing  to  an  ulcer  of  the  lesser  curvature,  but  does  not  in  any  way 
indicate  an  ulcer  at  the  pylorus.  As  to  the  second  point — delay  of 
the  stomach's  emptying  itself — such  a  condition  may  be  produced 
by  or  be  due  to  pyloric  spasm  associated  with  hypersecretion,  without 
organic  disease.  No  one  questions,  however,  that,  when  an  ulcer  is 
situated  at  the  pylorus,  it  may  and  does  produce  a  marked  delay  in 
motility,  and  therefore  we  can  restrict  this  method  of  diagnosis  to 
ulcers  which  are  situated  at  the  lesser  curvature  and  at  the  pylorus. 

AVhen,  however,  callous  ulcer  exists,  and  thereby  produces  marked 
contraction  of  portions  of  the  stomach,  it  is  readily  seen  in  the 
rontgenograph,  and  probably  can  be  discovered  in  no  other  way, 
when  not  situated  at  the  pylorus.  Furthermore,  this  form  of  ulcer 
often  produces  a  small  diverticulum,  which  shows  in  the  picture  as 
a  projection  from  the  stomach  contour,  and  which  often  remains, 
the  bismuth  appearing  as  a  shadow,  long  after  the  other  portions  of 
the  stomach  are  freed  from  their  bismuth  content.  This,  when  ap- 
pearing, as  it  usually  does,  at  the  lesser  curvature,  becomes  the  more 
significant,  since  ordinarily  this  outline  is  entirely  free  from  con- 
striction and  appears  in  a  uniform  line  with  the  rest- of  its  periphery. 
The  frequency  of  this  symptom,  even  when  callous  ulcer  exists,  is 
probably  overestimated,  since,  whenever  situated  on  the  posterior  or 
anterior  wall  of  the  stomach,  it  becomes  no  longer  visible.  This, 
again,  is  demonstrated  by  the  fact  that  there  are  patients  who  often 
present  a  perfectly  normal  gastric  picture,  and,  when  operated,  on 
account  of  the  persistence  of  their  symptoms,  are  found  to  have  this 
form  of  ulcer. 

The  second  and  most  important  form  of  the  callous  ulcer  is  indicated 
by  the  perfect  hourglass  stomach  on  the  plate.  When  this  appears, 
and  the  constriction  in  the  middle  of  the  stomach  is  constant,  with- 
out question  a  chronic  ulcer  is  present,  situated  at  this  point,  pro- 
ducing the  narrowing  of  the  organ. 

Unfortunately,  the  rontgenograph  cannot  tell  us  whether  the  hour- 
glass stomach  is  dependent  on  a  contraction  of  an  old  ulcer,  on  peri- 


124  DISEASES   OF   THE   DIGESTIVE   TRACT 

gastritis,  or  on  a  functional  tetanic  muscular  contraction  produced  by 
the  influence  of  the  ulcer.  On  the  contrary,  the  supposition  that  the 
distinction  can  be  made  by  the  rapid  filling  of  the  lower  portion  of 
the  stomach,  which  always  counts  in  favor  of  the  spasmodic  contrac- 
tion, has  not  been  substantiated  by  further  experience.  The  so- 
called  "snail"  form  of  the  stomach,  or  curling  up  of  the  lesser  curva- 
ture, so  that  the  pylorus  and  the  cardia  approach  each  other,  has 
also  lost  its  practical  significance  and  is  now  rarely  mentioned.  The 
determination  as  to  whether  a  callous  ulcer  has  penetrated  a  neighbor- 
ing organ  is  usually  supposed  to  be  demonstrated  by  the  presence 
of  an  air  bubble  over  a  diverticulum,  but  it  is  not  constant  and  has 
lost  its  significance. 

When,  after  the  departure  of  the  bismuth  from  the  stomach,  a 
portion  remains  upon  its  periphery,  it  is  significant,  of  course,  of  a 
penetrating  ulcer,  but  it  is  not  at  all  constant.  There  is  no  question, 
however,  that  diagnosis  of  the  hourglass  stomach  was  never  firmly 
grounded  until  we  were  able  to  use  the  x-ray  examination.  Usually 
this  appears  upon  the  plate  as  a  constriction,  indicating  a  contraction, 
due  to  scar  tissue  arising  from  ulcer. 

Pyloric  stenosis  is  unquestionably  readily  detected  by  means  of  the 
rontgenograph,  but  the  same  condition  can  also  be  detected  by  our 
former  means  of  diagnosis — namely,  the  tube — so  that  the  x-ray  ex- 
amination is  often  superfluous.  Furthermore,  the  extent  of  narrow- 
ing can  frequently  be  as  well  determined  by  the  amount  of  residue 
which  is  obtained  from  the  fasting  stomach  as  by  means  of  the  amount 
of  bismuth  retained  at  the  end  of  the  same  period.  On  the  con- 
trary, the  sound  cannot  distinguish  between  an  organic  and  a  func- 
tional stenosis,  as  can  be  done  by  means  of  the  x-ray.  In  addition,  a 
sound  will  and  can  give  us  light  as  to  the  amount  of  residue  which 
can  be  obtained  from  the  fasting  stomach  and  also  that  a  portion  of 
the  stenosis  is  due  to  spasm,  thus  indicating  an  ulcer  in  the  vicinity 
of  the  pylorus,  which  has  caused  a  permanent  narrowing,  facts  which 
the  radiograph  cannot  impart. 

Duodenal  ulcer  is  claimed  by  many  rontgenologists  to  exhibit  a 
clearly  defined  and  distinctive  picture  upon  the  plate;  others  rely  on 
various  activities  of  the  stomach  under  the  screen,  such  as  increased 
peristalsis,  opened  pylorus,  and  rapid  departure  of  the  bismuth  into 
the  duodenum.  None  of  these  latter  symptoms  have  been  proven 
to  be  constant  in  the  presence  of  a  duodenal  ulcer,  and,  in  all  proba- 
bility, diagnosis  by  these  means  can  be  made  only  when  sufficient 
distortion  has  occurred  to  prevent  the  filling  of  the  so-called  ' '  bishop 's 


PHYSICAL   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT        125 

cap."  When  the  duodenal  ulcer  is  situated  some  distance  from 
the  pylorus,  a  condition  which  rarely  occurs,  and  stenosis  has  been 
produced,  the  broader  shadow  of  the  duodenal  portion  above  the 
stenosis,  together  with  the  increased  peristalsis  of  that  portion,  give 
us  satisfactory  evidence  of  an  ulcer.  Such  conditions  are  extremely 
rare,  and  eminently  satisfactory  for  means  of  diagnosis  only  when 
they  occur.  On  the  whole,  it  seems  safer  to  rely  on  the  symptoms — 
gastric  analysis  and  the  presence  of  blood  in  the  stools — than  to 
base  our  diagnosis  on  the  appearance  of  a  duodenal  ulcer  upon  the 
plate. 

Gastric  cancer  forms  the  most  satisfactory  object,  apart  from  the 
hourglass  stomach,  for  the  exhibition  of  the  accuracy  of  the  x-ray 
diagnosis.  The  characteristic  appearances  are  filling  defects  in  the 
outline  of  the  stomach  wall,  marked  diminution  of  its  volume,  and 
missing  peristalsis.  When,  however,  the  growth  is  situated  at  the 
pylorus,  probably  producing  only  a  stenosis  of  that  organ,  together 
with  a  dilatation  of  the  stomach,  we  cannot  from  this  alone  determine 
whether  we  are  dealing  with  a  malignant  or  a  benign  process  at  this 
point.  Frequently,  after  exhausting  all  our  clinical  means  of  diag- 
nosis and  failing  to  reach  a  definite  conclusion  as  to  whether  malignant 
disease  exists,  the  radiograph  will  clear  up  the  matter  at  once.  On 
the  contrary,  early  diagnosis  of  carcinoma,  an  aim  to  which  all 
clinicians  are  aspiring,  is  seemingly  not  aided  in  any  way  by  the  use 
of  the  x-ray.  Furthermore,  another  important  question  as  to  whether 
malignant  growths  of  the  stomach  are  operable,  which  has  resisted 
all  previous  means  of  clinical  effort,  resists  equally  as  well  the  x-ray 
investigation.  On  the  whole,  while  the  x-ray  examination  is  a  valuable 
adjuvant  to  our  other  means  of  investigation,  so  far  it  does  not  seem 
advisable  to  rely  on  it  alone,  or  to  base  our  opinion  on  its  findings  when 
they  do  not  correspond  with  those  acquired  by  our  other  means  of  in- 
vestigation. 

Ptosis  of  the  stomach  and  adhesions  about  the  pylorus,  particularly 
associated  with  gallstones,  which  are  often  portrayed,  may  be  detected 
by  the  rontgenograph  on  account  of  the  fact  that  the  stomach  fails 
to  recede  to  the  left  when  its  content  leaves  it.  Furthermore,  usually, 
the  stomach  is  found,  particularly  its  antrum,  to  be  drawn  well  to 
the  right  of  the  vertebral  column. 

Intestines. — The  results  obtained  from  the  radiological  examination 
of  the  intestinal  tract  are  distinctly  disappointing.  As  to  changes  of 
position,  the  evidence  obtained  is,  of  course,  distinctive  and  positive, 
but,  as  no  one  has  yet  been  able  to  demonstrate  what  the  normal  posi- 


126  DISEASES   OF   THE   DIGESTIVE   TRACT 

tion  of  the  intestinal  parts  are,  such  portrayals  have  little  distinctive 
value. 

Tubercular  and  malignant  stenosis  of  the  small  intestine  can  be  de- 
tected only  when  they  reach  an  extreme  stage  of  narrowing,  and  can 
then  usually  be  made  out  by  physical  examination  in  the  form  of 
rigidity  of  the  immediate  portion  of  the  intestine  before  the  obstruc- 
tion. 

Adhesions  are  rarely  detected  except  at  the  ileocecal  valve  (Lane 
kink,  Jackson  membrane,  etc.),  which  are  shown  by  the  delay  of  the 
bismuth  mixture  in  entering  the  cecum,  and  by  the  increased  caliber 
of  the  lower  section  of  the  ilium.  Furthermore,  these  demonstra- 
tions often  exist  when  at  operation  the  surgeon  can  discover  no  reason 
for  the  delay  of  the  contents. 

Appendicitis  and  cecum  mobile  may  be  demonstrated,  but  the  ap- 
pendix so  often  fills  with  the  bismuth  mixture  when  no  symptoms  of 
inflammation  are  present  that  the  value  of  this  phenomenon  must  be 
largely  discounted. 

Tubercular  and  malignant  stenoses  of  the  colon  are,  however,  more 
often  detected  by  the  x-ray,  either  when  the  bismuth  is  taken  by  the 
mouth  or  injected  by  way  of  the  rectum.  Still,  the  radiologist  ^\ill 
often  hesitate  to  pronounce  an  interruption  of  the  continuity  of  the 
bismuth  shadow  the  result  of  organic  disease  on  account  of  the  fre- 
quency of  functional  spasm  of  the  colon.  Such  has  been  our  expe- 
rience, when  operation  showed  an  annular  carcinoma  of  the  descend- 
ing colon. 

With  reference  to  this  point,  the  views  of  others  may  not  be  with- 
out interest.  Hanisch  declares  that  the  x-ray  examination  of  the 
colon  is  satisfactory  under  conditions  as  here  stated.  In  the  first 
place,  the  bismuth  should  not  be  given  by  mouth  alone,  but  rectal 
injections  should  also  be  employed.  Furthermore,  the  rontgeno- 
graph  alone  is  not  sufficient,  and  the  patient  should  be  examined  in  a 
prone  position  before  a  screen  while  the  bismuth  is  being  injected 
into  the  rectum.  The  following  conditions  may  be  established  by 
these  means:  changes  of  position,  formation  of  loops,  dilatation  and 
stenoses  of  the  canal,  adhesions  and  spasms,  as  well  as  the  connection 
of  palpable  tumors  with  the  intestine.  By  this  means  true  stenosis  of 
the  intestine  can  usually  be  distinguished  with  moderate  certainty 
from  pressure  of  neighboring  growths,  spasms,  and  narrowing  by 
means  of  adhesions.  Complete  dependence  should  not,  however,  be 
placed  alone  on  this  means  of  investigation,  and  one  should  not  rely 
on  a  single  examination,  but  on  two  made  at  considerable  time  apart. 


PHYSICAL   METHODS   OF   EXAMINATION   OF   THE   DIGESTIVE   TRACT        127 

Only  rarely  is  a  positive  early  diagnosis  of  carcinoma  possible,  and  in 
most  eases  the  x-ray  examination  gives  sufficient  evidence  of  a  prob- 
able stenosis  to  warrant  an  exploratory  laparotomy. 

Jeomans  recommends  that  the  x-ray  examination  should  be  em- 
ployed only  as  confirmatory  of  the  results  of  previous  physical  ex- 
amination. Such  a  rontgenograph  will  show  abnormalities  with  refer- 
ence to  size  and  position  of  the  colon,  as  well  as  indicate  stenoses,  al- 
most as  accurately  as  they  can  be  demonstrated  by  operation.  He 
claims  that,  if  such  radiological  examinations  are  made,  operations 
will  become  far  less  numerous. 

Rectal  carcinoma,  if  high  up,  may  require  an  x-ray  examination  for 
its  diagnosis;  or  the  proctoscope,  if  the  growth  can  be  reached  by 
that  instrument,  will  give  us  much  clear  information  as  to  the  site 
and  character  of  the  growth. 

Coloptosis  and  megalocolon  often  demand  an  x-ray  examination, 
and  these  conditions,  being  based  on  a  change  in  position  and  size, 
probably  cannot  be  detected  by  any  readier  or  more  accurate  method. 

RECTOSCOPIC  EXAMINATION. 

The  rectoscopic  examination  of  the  lower  intestinal  tract  has  all  the 
advantages  of  radiology  in  the  detection  of  stenosis,  together  with  the 
added  value  of  offering  us  a  view  of  the  condition  of  the  mucous 
membrane,  including  any  ulcers,  bleeding  points,  benign  or  malig- 
nant growths,  or  bulging  due  to  the  pressure  of  pus  from  an  adjacent 
abscess.  The  introduction  of  the  well-oiled  instrument  may  be  made 
in  the  Sims  position,  when  air  must  be  blown  in  to  keep  the  intestinal 
folds  away  from  the  field  of  vision ;  or  the  knee-chest  position  may  be 
chosen,  which  by  gravity  and  atmospheric  pressure  straightens  the 
rectum  and  sigmoid  and  removes  some  of  the  angularities.  Hence 
there  are  two  types  of  instruments — those  following  the  Strauss 
model,  with  an  attachment  for  blowing  air  into  the  canal  at  the  inner 
end  of  the  instrument,  and  those  patterned  after  Schreiber  's  rectoscope, 
which  contains  no  such  attachment  and  relies  on  the  patient's  position 
for  facilitating  the  introduction.  Another  most  important  feature  is 
the  light,  which  can  be  obtained  from  a  small  battery  or  from  an 
electric  light,  controlled  by  a  good  rheostat.  This  lamp  can  be  placed 
either  at  the  distal  end  of  the  tube,  where  it  is  liable  at  any  moment  to 
be  obscured  by  feces  or  mucus,  or  at  the  proximal  end,  where  it  is 
under  constant  control  by  the  operator,  and  the  light  is  thrown  into 
the  canal  by  a  reflector.     The  lamp  and  its  reflector  take  up  so  little 


128 


DISEASES   OF   THE   DIGESTIVE   TRACT 


room  that  all  manipulations  may  take  place  through  the  tube,  but  the 
current  must  be  fairly  strong  (0.7  ampere,  5-7  volts)  to  illuminate  the 
distant  stretches  of  the  sigmoid.  Now,  while  a  short  instrument — a 
true  rectoscope — is  most  advantageous  for  the  investigation  of  the 
ampulla  or  for  treatment,  a  long  instrument  must  be  introduced  if 
the  lesion  is  not  found  there  and  we  wish  to  investigate  the  region 
higher  up,  which  necessitates  the  removal  of  this  one  and  the  intro- 
duction of  another  much  longer — a  true  romanoscope.     On  account  of 


1$'! 


Fig.  22. — Von  Aldor's  rectoromanoscope.     A,  tube  in  three  parts,  a,  b  and  c;  e,  obturator; 

d,  attachment  for  lamp. 

these  special  needs,  von  Aldor  has  devised  a  combination  of  the  two 
instruments,  of  which  a  figure  and  an  explanation  are  given.  (Fig. 
22.)  This  instrument,  which  is  made  by  the  Berlin  ^Medical  Ware- 
house, consists  of  three  tubes  (a,  b,  c)  of  a  length  of  10  cm.  each,  which 
can  be  attached  to  each  other  by  finely  threaded  screws  or  by  a 
bayonet  attachment;  an  obturator  (e),  which  can  be  inserted  into  the 
first  one  (a)  to  facilitate  introduction,  an  attachment  (d)  for  holding 
the  lamp,  and  the  lamp  itself.     These  tubes  are  graduated  into  centi- 


PHYSICAL,   METHODS   OP   EXAMINATION   OP   THE   DIGESTIVE   TRACT       129 

meters,  and,  when  united,  give  a  scale  of  1-30  em.  The  obturator  fits 
only  the  first  section,  as  it  is  never  needed  after  the  introduction  of 
the  first  portion,  and  the  distal  end  of  the  first  section  has  a  round,  dull 
edge.  This  enables  one  to  proceed  from  the  examination  of  the 
rectum  to  that  of  the  sigmoid  by  simply  uniting  one  section  of  the 
tube  after  another  and  slipping  on  the  attachment  for  holding  the 
lamp,  thus  doing  away  with  a  series  of  instruments  of  different  lengths 
and  their  obturators.  The  lamp  is  the  ordinary  diminutive  electric 
bulb,  requiring  usually  a  current  of  only  0.40  amperage  and  four 
volts,  which  is  placed  in  a  pocket  or  depression  in  the  side  of  the 
tube,  having  a  window  only  in  that  part  directed  toward  the  distal 
portion  of  the  intestine,  while  the  rest  of  the  receptacle  is  converted 
into  a  reflector.  Thus  the  lamp  itself  is  so  protected  that  it  cannot 
be  easily  broken  or  soiled,  and  takes  up  so  little  of  the  lumen  of  the 
tube,  since  it  does  not  project  more  than  a  few  millimeters  beyond 
the  inner  periphery,  that  manipulations  through  it  are  not  restricted. 
The  directions  for  the  use  of  the  instrument  are  very  simple.  The 
patient,  without  any  unnecessary  preliminary  cleansing  enema,  as- 
sumes the  knee-chest  position,  and,  after  the  introduction  of  the  first 
section  with  its  well-oiled  obturator,  the  latter  is  withdrawn,  the 
lamp  inserted  on  the  sacral  surface,  and  the  left  hand  assumes  wholly 
the  direction  and  further  advance  of  the  rectoscope,  leaving  the  right 
hand  free  to  remove — by  means  of  a  long  applicator  armed  with  cot- 
ton, which  may  also  be  oiled  to  remove  any  fragments  or  feces  obscur- 
ing the  vision — any  flecks  of  mucus  which  may  obscure  ulcerations. 
By  slowly  pushing  the  instrument  forward,  waiting  a  moment,  if  it 
meets  resistance,  for  the  spasm  to  subside,  or  smearing  the  tissue  be- 
yond the  tube  with  tepid  oil,  it  is  usually  possible  to  reach  the  sig- 
moid without  difficulty,  and  a  perfect  view  may  be  obtained  of  ulcera- 
tions, polypi,  etc.,  even  at  that  distance  from  the  light. 


CHAPTER  V 

ACQUISITION  AND  EXAMINATION  OF  GASTRIC 
CONTENTS 

After  so  many  years'  employment  of  the  described  method  of 
solving  the  problems  attendant  on  disorders  of  digestion,  it  peeds  no 
defense,  and  the  only  reason  why  this  method  has  fallen  into  disre- 
pute with  some  practitioners  is  that  by  its  means  alone  they  expect  to 
make  a  diagnosis,  while  one  well  versed  employs  the  analysis  of  gastric 
content  as  only  one  of  the  means  of  examination,  faithfully  endeavor- 
ing with  all  means  at  his  disposal  to  form  a  composite  picture  of  the 
disease  before  him.  For  obtaining  gastric  content,  nothing  better  has 
ever  been  devised  than  the  Jacques  tube  of  soft  rubber,  with  a  closed 
end  and  two  side  openings,  whose  edges  should  not  be  too  sharp,  or,  if 
they  are,  should  be  dulled  by  passing  a  red-hot  needle  over  them.  The 
length  of  this  tube  should  be  75  cm. ;  its  caliber,  8  mm. ;  and  its  diame- 
ter, 12  mm.  Such  tubes  have  been  used  by  the  writer  for  years,  but  the 
great  disadvantage  is  that  they  are  made  abroad,  and,  after  several  un- 
successful efforts  to  secure  an  equally  good  article  from  American  rub- 
ber companies,  we  had  better,  in  the  writer's  opinion,  let  the  stomach 
tubes  be  "made  in  Germany."  All  bulbs,  funnels,  and  cups  incor- 
porated in  the  tube  are  entirely  unnecessary,  and  complicate  an  other- 
wise very  simple  and  easily  cleaned  instrument.  It  is  particularly 
desirable,  in  buying  such  an  article,  to  demand  that  the  tip  be  made 
of  solid  rubber  for  some  distance  before  the  interior  of  the  tube  be- 
gins, but  the  latter  should  extend  beyond  the  second  side  opening  a 
short  distance,  so  that  a  probang  may  be  introduced  inside  the  tube 
to  guide  it  if  necessary.  For  cleaning  the  tubes,  it  is  only  necessary 
to  wash  them  well  externally  with  soap  and  water,  after  which  run 
water  through  them,  which  can  be  readily  done  by  passing  the  open 
end  inside  a  faucet  outlet,  and  boil  them  out  if  any  suspicion  of  malig- 
nant or  specific  disease  in  the  patient  exists.  The  introduction  of  the 
sound  is  best  accomplished  with  the  patient  in  the  sitting  posture,  with 
the  head  bent  slightly  forward.  The  writer's  experience  with  the  pa- 
tient lying  down  has  never  been  satisfactory,  as  the  tube  more  readily 
enters    the    larynx.     The    individual    should    be    allowed    a    sip    of 

130 


ACQUISITION   AND   EXAMINATION   OP   GASTRIC    CONTENTS 


131 


water — false  teeth,  if  present,  should  be  removed — and,  when  the 
end  of  the  tube  is  against  the  pharynx,  the  patient  should  be  asked  to 
swallow,  the  physician  at  the  same  time  passing  the  instrument 
rapidly  into  the  stomach  after  being  assured  by  the  absence  of  air 
rushing  through  the  tube  that  it  is  not  in  the  larynx.  Two  difficulties 
are,  however,  liable  to  be  met — first,  inability  of  the  patient  to  swal- 
low, due  to  spasm  of  the  pharynx,  and,  second,  an  almost  cramplike 
closure  of  the  teeth  on  the  tube,  preventing  its  further  introduction. 


0^ 


■^m 


m 


Fig.  23. — Gastric  tube. 


a.  lower  end  of  the  gastric  tube;  h,  cross  section  of  the  tube;  enlarged 
one-half  natural  size. 


Both  these  difficulties  can  frequently  be  overcome  by  asking  the  indi- 
vidual to  hold  the  receptacle  which  is  to  receive  the  contents.  It  is 
amusing  sometimes  to  note  the  patient's  almost  cramplike  grasp  of 
this  vessel,  which  requires  force  to  remove  it  from  his  hands,  yet  it 
distracts  his  attention  and  lessens  the  pharyngeal  spasm,  which  seems 
to  be  partially  voluntary.  After  the  tube  has  been  introduced  to  a 
depth  of  50  cm.  or  more,  the  contents  often  flow  at  once ;  if  not,  the  pa- 
tient is  asked  to  press  as  at  stool,  or,  by  moving  the  tube  back  and 


132 


DISEASES   OF   THE   DIGESTIVE    TRACT 


forth,  efforts  at  vomiting  are  incited,  which  force  out  the  contents. 
After  the  fluid  has  ceased  to  flow,  or  even  if  it  does  not  flow  freely, 
the  outer  end  of  the  tube  should  be  pinched  against  the  side  of  the 
vessel  with  the  right  hand  and  the  instrument  withdrawn  with  the 
left,  allowing  any  contents  in  the  tube  to  run  into  the  glass.  Even 
when  fluid  does  not  run  out  of  the  tube  in  this  way,  sufficient  will  be 


POSTERIOR  WALL 
OF  PHARYNX 


EPIGLOTTIS 


LARYNX 


Fig.  24. — Sectional  view  of  the  tube  "in  place  between  larynx  and  post-pharyngeal  wall. 

found  in  it  for  the  quantitative  tests.  Another  way,  if  the  contents 
do  not  flow,  is  to  have  a  Politzer  bulb  at  hand,  which  can  be  com- 
pressed, inserted  into  the  outlet  of  the  tube,  allowed  to  expand,  and 
removed,  when  the  flow  will  often  start.  As  a  substitute  for  the 
Politzer,  an  ordinary  oval  bulb  of  thick  rubber  may  be  used,  into  the 
open  ends  of  which  two  glass  unions  may  be  inserted  that  taper  at 
one  end,  which  may  be  inserted  into  the  open  end  of  the  stomach  tube. 


ACQUISITION   AND   EXAMINATION   OF    GASTRIC    CONTENTS  133 

If  we  wish  to  aspirate,  we  may  compress  the  bulb  after  insertion  and 
hold  the  tip  of  one  finger  over  the  open  end,  or,  by  placing  the  finger 
tip  over  the  end  and  then  compressing  the  bulb,  we  may  force  air 
through  the  tube  to  dislodge  a  crumb  of  bread  or  any  obstacle  which 
may  be  occluding  the  tube.  This  bulb  has  a  great  advantage  over  the 
Politzer  in  that  it  can  be  more  easily  cleaned,  and  by  means  of  the  glass 
tube  we  can  see  whether  any  fluid  has  been  raised  from  the  stomach. 
Furthermore,  by  pinching  the  tube  and  compressing  the  bulb  we  may 
force  into  the  vessel  any  gastric  content  and  repeat  the  process.  In 
some  stomach  tubes  this  bulb  has  been  incorporated  in  the  tube  itself, 
but  from  hundreds  of  removals  of  gastric  contents  the  writer's  expe- 
rience is  that  in  so  few  is  aspiration  needed  that  it  is  better  to  use 
the  bulb  as  an  accessorj'^  rather  than  as  a  constituent  part  of  the  out- 
fit. Besides  the  condition  mentioned  where  no  fluid  flows  from  the 
tube — probably  on  account  of  an  atonic  stomach,  lax  abdominal  walls, 
and,  as  at  times  seems  assured,  corsets  in  women,  and  where  with  with- 
drawal of  the  tube  with  tightly  pinched  outlet  will  often  secure  us  as 
much  as  10  c.c.  of  content — we  occasionally  come  on  instances  where 
none  of  these  artifices  are  of  any  avail.  Some  are  cases  of  increased 
peristalsis  with  normal  pylorus,  some  of  achylia,  where,  contrary  to 
general  opinion,  it  is  not  increased  motility,  but  lack  of  gastric  juice, 
which  prevents  us,  because,  pouring  in  a  small  amount  of  water  and 
then  lowering  the  tube,  we  may  cause  to  flow  out  practically  all  the 
bread  of  the  test  breakfast ;  and  some  examples  of  a  low  lying  stomach 
in  which  the  eyes  of  the  tube  cannot  reach  the  level  of  the  fluid.  In 
all  such  cases  it  is  well  to  pour  in  250  c.c.  of  water  through  a  small 
funnel  inserted  into  the  tube,  which  so  stimulates  the  contraction  of 
the  stomach  that  the  contents  readily  flow  out  on  lowering  the  end  of 
the  tube.  While  such  diluted  contents  are  useless  for  chemical  exam- 
ination, their  macroscopic  and  microscopic  appearance  may  be  of 
great  value. 

]\Iuch  has  been  said  about  the  preparation  of  the  patient  and  the 
tube  for  removal  of  gastric  contents.  Some  advise  cocainizing  the 
pharynx  of  the  patient  and  chilling  the  end  of  the  tube,  but  the 
writer's  experience  has  been  that  a  swallow  of  water  and  as  little  fuss 
and  as  great  speed  as  possible  on  the  part  of  the  physician  lead  oftenest 
to  the  desired  end.  ]\Iore  sufi^ering  is  caused  the  patient,  at  least  men- 
tally, by  thinking  about  the  act  after  the  formal  announcement  on 
the  part  of  the  doctor,  or  from  the  old  woman's  tales  of  others  who 
have  had  it  done,  than  by  the  process  itself.  In  the  writer's  college 
days  the  tales  of  hazing,  which  were  intentionally  exaggerated,  caused 


134  DISEASES   OP   THE   DIGESTIVE   TRACT 

more  fear  than  the  demonstration  itself  when  it  arrived,  and  this 
is  equally  true  of  the  passage  of  the  tube,  described  as  "pumping 
the  stomach"  to  the  victim  by  others  who  have  had  it  done  and  are 
not  above  a  mild  exaggeration.  The  individual  with  whom  absolutely 
nothing  can  be  done  is  one  who  persists  in  pulling  out  the  tube,  such 
as  one  often  meets  among  the  ignorant  frequenters  of  a  clinic,  and 
with  such,  after  the  exhibition  of  a  fair  share  of  patience,  the  writer 
refuses  to  have  anything  to  do.  In  the  writer's  experience  failures 
have  occurred  oftener  when  others  were  looking  on,  such  as  students 
in  the  clinic  or  overanxious  relatives  in  the  office,  when  patients  seem 
especially  excited  and  subject  to  spasm,  so  that  the  physician  should 
learn  as  far  as  possible  to  work  without  assistants,  or,  what  is  still 
better,  make  the  patient  an  assistant  in  the  manner  mentioned  above. 
It  has  already  been  stated  that  the  tube  may  be  sometimes  introduced 
into  the  larynx,  which  is  instantly  indicated  by  cough  and  air 
whistling  through  the  tube  in  respiration.  This  happens  both  when 
the  head  is  thrown  backward  and  when  the  patient  fails  to  cooperate 
by  swallowing,  particularly  if  we  attempt  to  force  the  tube  against 
the  resistance  of  a  pharyngeal  spasm,  and  the  tube  should,  of  course, 
be  immediately  withdrawn  and  another  effort  made.  Then,  too,  we 
should  watch  the  face  of  the  patient,  as  it  may  become  dusky — either 
because  he  voluntarily  holds  his  breath,  like  the  crying  child,  or  spasm 
of  the  vocal  cords  occurs,  so  that  croupy  breathing  may  be  heard,  and 
both  are  indications  for  the  removal  of  the  tube.  "While  these  com- 
plications are  to  be  borne  in  mind,  it  is  astonishing  how  many  hun- 
dreds in  a  large  clinic  will  have  the  tube  passed,  often  by  inexpe- 
rienced assistants,  without  a  failure.  When  a  patient  almost  faints 
at  the  sight  of  the  tube,  is  pale  and  trembling,  it  is  well  to  appoint 
another  day  for  the  act,  when  he  or  she  may  be  more  composed.  The 
fear  of  causing  a  hemorrhage  with  the  sound,  even  in  chronic  ulcer, 
is  exaggerated,  for  it  has  occurred  only  twice  in  the  writer's  expe- 
rience in  many  hundred  cases,  and  even  then  the  amount  of  blood 
coming  from  the  tube  was  trifling.  The  patients,  qne  a  young  Hebrew, 
a  bleeder,  and  the  other  a  sufferer  from  chronic  gastric  ulcer  (who 
had  had  no  spontaneous  hemorrhage  for  a  year)  were  not  harmed  by 
the  process.  It  is  also  remarkable  that  even  cases  of  gastric  neurosis 
are  benefited  by  the  passage  of  the  tube,  for  by  its  findings  one  is 
enabled  to  assure  the  patients  that  no  organic  disease  exists,  a  con- 
dition which  they  have  been  dreading.  The  indications  for  the  use 
of  the  tube  are  to  first  clear  up  the  question  of  esophageal  stenosis, 
for,  when  it  is  spasmodic  in  character,  the  soft  tube  works  better 


ACQUISITION   AND   EXAMINATION    OF    GASTRIC    CONTENTS  135 

than  the  stiff  probang.  Outside  of  this,  of  course,  the  main  object 
of  the  use  of  the  tube  is  to  obtain  the  gastric  contents,  which  should 
be  done  whenever  other  means  of  examination  do  not  show  us  readily 
that  there  exists  a  pure  gastric  neurosis  or  nervous  dyspepsia,  as  it  is 
sometimes  called.  Even  then  we  have  variations  in  the  acidity  of 
the  content,  varying  from  entire  absence  in  achylia  to  an  excess — 
hyperchlorhydria — conditions  which  produce  most  of  the  symptoms, 
and  which  we  cannot  treat  intelligently  without  a  definite  knowledge 
of  their  presence.  In  the  meantime  it  cannot  be  too  much  emphasized 
that  we  should  not  be  content  with  such  an  examination  of  gastric 
contents  alone.  It  can  be  easily  seen  that  in  one  instance — that  of 
heartburn,  so-called — no  intelligent  therapy  can  be  employed  until 
by  the  use  of  the  tube  and  examination  of  gastric  contents  we  can 
determine  whether  it  is  due  to  relaxed  cardia,  hypersecretion,  or 
fermentative  processes.  Perhaps  the  rule  of  E.  Schuetz  is  as  good  as 
any — that  in  comparatively  fresh  cases,  if  no  relief  from  diet  and 
medicinal  treatment  is  obtained  in  a  period  of  fourteen  days,  we 
should  proceed  at  once  to  the  passage  of  the  tube;  this  will  avoid  its 
unnecessary  employment,  and  at  the  same  time  prevent  us  from  long 
continued,  unavailing  treatment  of  a  supposed  functional  disorder 
when  a  chronic  ulcer,  achylia,  or  early  gastric  cancer  may  be  the  origi- 
nating cause  of  the  digestive  symptoms. 

CONTRAINDICATIONS. 

The  contraindications  to  the  use  of  the  tube,  apart  from  the  in- 
stances mentioned  where  it  is  impracticable,  are  found  in  all  forms  of 
heart  disease  or  damaged  arteries,  though  in  well-compensated  mitral 
regurgitation  it  has  been  the  writer's  practice  to  employ  it  for  many 
years  without  any  damage  so  far.  If  there  is  the  slightest  suspicion 
of  cardiac  disease  in  the  pallor,  rapid  breathing,  or  dusky  lips  of  the 
patient,  the  stethoscope  should  always  be  used  and  the  condition  of 
the  heart  learned.  Severe  anemia  and  advanced  age  are  also  deter- 
rents to  the  use  of  the  tube.  Previous  gastric  hemorrhage  is  no 
hindrance,  provided  that  four  weeks  have  elapsed  since  the  hema- 
temesis.  An  examination  of  gastric  contents  during  menstruation 
should  never  be  made  on  account  of  the  marked  physiological  changes 
in  the  gastric  juice  at  that  time,  almost  approaching  the  pathological. 
This  manifests  itself  as  a  hypersecretion  which  in  some  approaches  the 
continuous  secretion  type.  At  the  same  time  the  motility  of  the 
stomach  is  distinctly  diminished. 


136  DISEASES   OF   THE   DIGESTIVE   TRACT 


EXAMINATION  OF  GASTRIC  CONTENTS. 

The  examination  of  gastric  contents  may  be  employed  on  the  con- 
tents of  the  food-containing  stomach,  or  on  those  of  the  fasting  indi- 
vidual (one  who  from  the  lapse  of  time  should  physiologically  be  fast- 
ing), to  learn  the  character  of  the  residue  in  retention  or  hypersecre- 
tion— both  pathological  conditions.  As  a  general  rule,  we  examine 
the  contents  of  the  food-containing  stomach,  since  food  forms  the 
best  stimulation  of  the  gastric  juice,  the  so-called  "digestive  stimula- 
tion," to  investigate  the  motor  and  secretive  functions  of  that  organ. 
Two  things  must  be  borne  in  mind — that,  for  comparison  with-  normal 
conditions,  the  food  must  be  of  the  same  character  and  amount,  and 
the  contents  must  be  removed  at  the  same  interval  after  food  is 
taken. 

TEST  MEALS. 

1.  The  so-called  Ewald-Boas  test  breakfast  consists  of  a  slice  of 
white  bread  (30-35  grams)  and  a  glass  and  a  half  of  water  (400  c.c), 
which  should  be  taken  fasting  and  removed  one  hour  after  it  is  eaten. 
A  normal  stomach  should  be  empty  two  hours  after  this  is  taken,  and 
the  tube  may  be  introduced  at  this  interval  to  test  the  motility,  but 
this  is  not  as  satisfactory  for  the  purpose  as  the  meal  mentioned  be- 
low. It  is  needless  to  say  that  the  bread  must  be  well  masticated  and 
the  water  taken  after  the  bread  is  eaten. 

2.  An  evening  meal,  a  combination  of  the  Riegel  and  Boas  meals, 
consisting  of  meat,  potato,  bread,  and  butter,  with  the  customary  bev- 
erage— a  cup  of  tea,  coffee,  or  cocoa,  or  a  glass  of  water — to  which, 
for  purposes  mentioned  later,  we  may  add  a  saucer  of  cooked  rice 
with  raisins,  or,  better  still,  some  rice  pudding  with  raisins.  The 
stomach  is  to  be  emptied  approximately  twelve  hours  afterward,  or 
the  next  morning,  and  washed  out,  when  the  test  breakfast  can  be 
given  and  the  patient  retained  an  hour  for  the  second  expression,  as 
described  in  the  writer's  article  on  "The  Significance  of  the  Ratio 
of  Free  Hydrochloric  Acid  to  the  Total  Acidity  in  Determining  Im- 
paired Motility  of  the  Stomach."^ 

3.  In  addition  to  the  above,  the  author  has  made  extensive  use  of 
the  so-called  "water  meal"  for  determining  both  the  secretory  and 
the  motile  powers  of  the  stomach.  This  is  based  on  the  investigations 
of  Carlson  and  others,  who  showed  that  water  alone  had  a  marked 


^  Med.   Record,  vi.    8.    1912. 


ACQUISITION   AND   EXAMINATION   OF    GASTRIC    CONTENTS  137 

influence  in  stimulating  gastric  juice.  From  them  we  learn  that 
water  alone  may  induce  a  gastric  juice  whose  acidity  is  about  100  in 
less  than  twenty  minutes  after  stimulation,  during  which  time  prac- 
tically all  of  the  water,  amounting  to  500  c.c,  enters  the  intestine.  In 
addition,  any  residue  left  in  the  stomach  from  the  evening  before, 
if  the  water  is  given  fasting,  can  be  detected.  As  applied  to  clinical 
use,  in  which  the  author  has  employed  it  in  many  hundreds  of  cases, 
the  patient  is  asked  to  take  the  evening  before  examination  a  meal 
of  meat,  potato,  bread,  and  butter,  with  rice  and  raisins,  and  then 
come  to  the  clinic  the  next  morning  fasting.  There  250  c.c.  of  water 
are  given  the  patient  and  the  contents  of  the  stomach  removed  twenty 
minutes  later,  the  extreme  limit  at  which  these  authors  claim  that  the 
water  given  has  left  the  stomach.  The  average  of  acid  values  with 
this  meal  is  found  to  be  practically  20  for  free  hydrochloric  and  30  for 
total  acidity. 

4.  For  determining  the  motility  of  the  stomach,  chlorophyl,  which 
is  not  absorbed  from  either  the  stomach  or  intestines,  has  been  used 
by  Boas.  The  patient  is  asked,  while  fasting,  to  drink  400  c.c,  of 
water  to  which  20  drops  of  the  coloring  substance  have  been  added. 
After  thirty  minutes,  whatever  remains  of  the  water  in  the  stomach 
is  removed  by  the  stomach  tube.  The  amount  of  coloring  matter  re- 
moved can  be  approximately  estimated  by  the  colorimetric  method — 
that  is,  comparison  with  the  same  amount  of  coloring  matter  diluted 
to  meet  the  intensity  of  the  color  of  that  removed.  It  has,  how- 
ever, been  found  by  the  author  that  this  method  can  be  satisfactorily 
combined  with  the  above-mentioned  water  meal,  and,  whenever  any 
of  the  coloring  matter  remains  in  the  fluid  removed  after  twenty 
minutes,  we  may  consider  that  there  is  a  degree  of  deficient  motility 
on  the  part  of  the  stomach.  The  presence  of  bile  may  sometimes 
interfere  with  the  quick  appreciation  of  the  presence  of  chlorophyl, 
but,  of  course,  any  of  the.  tests  for  bile,  preferably  the  nitrous  and 
nitric  acid  tests,  will  promptly  distinguish  between  them. 

As  will  l)e  seen,  the  first  meal  is  to  test  the  secretory  function  of 
the  stomach,  while  the  second  may  serve  equally  well  as  a  measure 
of  motility  or  oversecretion.  ]\Iany  have  been  dissatisfied  with  the 
test  breakfast,  claiming  that  it  furnishes  too  slight  a  stimulus,  and 
that  a  stomach  which  will  readily  take  care  of  it  will  fail  to  dispose 
of  a  larger  meal,  and  employ  the  Riegel  meal,  which  is  practically  the 
evening  meal  mentioned  above,  but  is  to  be  removed  three  to  four 
hours  after  it  is  taken.  The  latter  has  been  unsatisfactory  in  the 
writer's  practice,  because  fragments  of  undigested  meat  frequently 


138  DISEASES   OP   THE   DIGESTIVE   TRACT 

occlude  the  tube,  and  often  a  large  mass  of  fat  collects  on  top  of  the 
contents  when  placed  in  a  glass,  smearing  all  utensils  used  in  the  ex- 
amination. Another  disadvantage  of  the  Riegel  meal  is  that  the 
time  of  removal  is  not  accurately  determined,  that  free  hydrochloric 
acid  is  less  liable  to  appear — even  when  the  simple  breakfast  indi- 
cates its  presence — and  that  the  so-called  "layer  formation"  in  the 
stomach  is  more  pronounced  and  interferes  much  more  with  a  com- 
posite picture  of  the  secretory  function.  Hence  the  writer's  practice 
is  to  confine  himself  to  the  test  breakfast  and  the  evening  meal,  which 
so  far  have  fulfilled  all  his  requirements.  Strauss  and  others  have 
recommended  the  use,  with  the  evening  meal,  of  currants,  raisins, 
and  prunes,  because  they  leave  the  stomach  less  readily  than  do  other 
foods,  and  by  their  color  and  form  are  much  more  readily  detected 
in  the  stomach  washings.  It  came  to  the  writer's  attention  acciden- 
tally that  the  shells  of  lima  beans  were  often  found  in  the  fasting- 
stomach  washings,  and  he  has  therefore  had  them  added  to  the  eve- 
ning meal  with  success.  The  stomach  of  the  ' '  morning  after ' '  should 
be  free  from  any  residue,  and  the  presence  of  any  remnants,  however 
small — ' '  minimal  retention ' ' — shows  lacking  motility,  pyloric  stenosis, 
or  scar  tissue  from  an  old  ulcer  not  at  the  pylorus,  as  shown  by  two 
cases  of  the  writer  at  operation.  On  the  contrary,  absence  of  food 
remnants  does  not  preclude  a  lesser  degree  of  impaired  motility.  The 
writer's  practice  is  always  to  allow  the  washings  from  the  fasting 
stomach  to  remain  in  a  large  conical  glass  for  a  time,  then  the  super- 
natant fluid  is  poured  off  and  the  residue  centrifuged;  to  the  second 
residue  a  few  drops  of  Lugol's  solution  are  added,  which  causes  the 
fragments  of  starch  (rice),  which  also  leave  the  stomach  last,  to  be 
stained  deeply  blue,  when  they  can  be  seen  with  the  naked  eye,  or 
very  readily  with  the  microscope.  Attention  is  called  to  careful 
mastication,  for  great  crumbs  of  bread — such  as  are  seen  after  the 
test  breakfast,  or,  where  there  is  marked  gastric  insufficiency,  in  the 
washings  of  the  fasting  stomach  after  the  evening  meal — have  very 
little  significance  when  the  teeth  are  poor  or  the  eating  is  rapid. 

The  superficial  advantages  of  the  water  meal  are  readily  recognized. 
Bread  is  not  always  available  in  the  clinic  for  the  test  breakfast,  but 
water,  of  course,  is.  We  can  never  rely  on  the  time  if  patients  are 
allowed  to  take  their  bread  at  home  and  then  come  to  the  clinic, 
while,  if  taken  after  arrival,  a  wait  of  forty-five  to  sixty  minutes  is 
too  long  in  a  busy  forenoon.  Water,  too,  as  remarked  by  the  before- 
mentioned  authors,  allows  one  to  see  readily  whether  there  is  any  resi- 
due left  from  the  Riegel  meal.     This  method  also  avoids  a  second  in- 


ACQUISITION   AND   EXAMINATION   OP    GASTRIC   CONTENTS  139 

troduetion  of  the  tube,  which  is  necessary  if  we  first  attempt  to  find 
food  remnants  in  the  fasting  stomach  and  then  give  the  ordinary  test 
breakfast.  Lactic  acid,  blood,  and  bile  are  also  much  more  readily 
detected  in  the  absence  of  a  mass  of  partially  digested  food.  A  more 
complete  description  of  this  method  is  given  by  the  author  in  an 
article  recently  published.^ 

The  advantage  of  the  chlorophyl  method  of  determination  of  mo- 
tility consists  chiefly  in  the  fact  that  no  pyloric  reflexes  are  incited 
and  that  the  remaining  fluid  is  easily  withdrawn.  No  layers  are 
formed  by  this  means  and  finally,  under  the  pathological  conditions, 
the  motility  can  be  determined  in  a  very  short  time.  By  estimating 
the  percentage  of  chlorophyl  which  has  left  the  stomach  during  this 
period,  one  can  easily  obtain  a  standard  for  the  greater  or  less  motile 
power  of  the  stomach,  and  can  say  that  this  method  far  surpasses  the 
Riegel  method  in  accuracy  and  readiness  of  employment. 

Prom  my  experience  in  the  clinic,  carried  out  on  many  hundreds 
of  patients,  it  has  been  learned  that  when  a  proportional  amount  of 
chlorophyl  (10  drops)  is  added  to  the  water  meal  of  250  c.c,  normal 
stomachs  usually  pass  it  on  to  the  intestine  during  the  twenty-minute 
period,  and  that  the  presence  of  any  amount  of  chlorophyl  is  fully  as 
significant  as  the  determination  of  the  absolute  amount  retained,  as 
secured  by  the  Boas  method.  Of  course,  we  can  say  only  that  the 
stomach  has  either  normal  motility  or  moderately  impaired  motility 
instead  of  the  absolute  amount  of  impairment. 

By  giving  the  Riegel  meal  the  evening  before,  when  no  food  rem- 
nants are  found,  we  may  say  that  there  is  no  serious  impairment  in 
the  sense  of  a  stenosis ;  by  detection  of  the  presence  of  chlorophyl  we 
may  say  that  the  motility  is  moderately  diminished,  and  conclude  that 
it  is  probably  due  to  gastroptosis  or  to  a  condition  termed  gastric 
myasthenia. 

Three  factors  enter  into  the  investigation  of  the  gastric  contents 
— the  macroscopic  and  microscopic  appearance  and  the  chemical  ex- 
amination. 

MACROSCOPIC  EXAMINATION. 

The  macroscopic  examination  includes,  first,  the  amount  and  ap- 
pearance of  the  gastric  contents.  The  amount  is  dependent  on  the 
motility,  whose  increase,  of  course,  diminishes  the  volume  and  vice 
versa,  while  with  normal  motility  an  exaggerated  secretion  increases 
it.     If  one  were  always  sure  of  removing  all  the  contents,  these  rela- 

1  Boston  Med.  and  Surg.  Journ.,  Ixii,  No.  23,   1915,   857-859. 


140  DISEASES   OF    THE   DIGESTIVE   TRACT 

tions  would  be  evident,  but,  as  a  portion  is  always  solid  and  does  not 
flow  as  readily,  we  never  know  how  much  remains.  An  effort  has  been 
made  to  overcome  this  difficulty  by  pouring  into  the  stomach  a  meas- 
ured quantity  of  water  (200-250  c.c.)  by  means  of  a  funnel,  and  then, 
by  raising  and  lowering  the  water,  to  produce  a  thorough  mixture  of 
what  remains  with  the  water  in  an  attempt  to  form  a  homogeneous 
solution.  Some  prefer  to  use  a  larger  amount  of  wash  water  and 
wash  out  the  stomach  twice  with  a  liter  each  time,  but,  whatever 
amount  is  used,  that  returning  from  the  organ  must  be  measured. 
Then,  to  determine  the  total  gastric  content,  we  have  only  to  obtain 
the  acidity  of  the  original  or  first,  content  with  phenolphthalein 
and  that  of  the  residue  and  the  wash  water,  which  we  may  call  No. 
2;  multiply  this  volume  by  its  acidity  and  divide  by  the  acidity  of 
the  original  amount,  to  obtain  the  contents  remaining  in  the  stomach. 
Por  example,  suppose — to  use  the  illustration  of  J.  Schuetz,  who 
recommends  the  method — the  original  gastric  content  amounted  to 
SO  c.c,  with  an  acidity  of  50  (50  e.e.  N-10  sodium  hydroxide  to 
neutralize  100  c.c.  gastric  content),  and  the  wash  water  amounted  to 

2,000  c.c,  with  an  aciditv  of  10.  We  have  then  ^'^-^  ^^  =  400 
remaining  in  the  stomach,  which,  added  to  the  80  ce.  undiluted,  makes 
a  total  gastric  content  of  480  c.c.  The  great  objection  to  any  of  these 
methods  is  that  we  are  unable  to  obtain  a  homogeneous  mixture,  for 
the  solid  portions  carrj^  a  large  amount  of  acid  united  firmly  with 
them,  and,  on  account  of  sedimentation,  it  is  difificult  to  distribute 
these  so  as  to  obtain  an  average  acidity  for  the  whole.  Then,  again, 
an  increase  of  the  residual  content  in  the  stomach  does  not  allow  one 
to  exclude  a  hypersecretion.  Hence  we  are  never  able  to  say  with 
accuracy  how  much  content  there  may  be  at  any  interval  because  we 
do  not  know  how  much  is  left  nor,  on  account  of  the  wide  variations 
in  the  time  of  emptying  of  a  perfectly  normal  stomach,  can  we  say 
with  definiteness  how  much  average  gastric  content  is  normal  or  in- 
creased at  any  period  after  the  food  is  taken.  Yet,  by  collecting  the 
results  of  many  examinations,  one  may  say  that  an  excess  of  120  c.c. 
of  undiluted  gastric  contents  withdrawn  one  hour  after  the  test  break- 
fast must  be  considered  pathological,  without  furnishing  any  infor- 
mation as  to  whether  there  is  a  lacking  motility  or  increased  secretion. 
To  overcome  this  lack,  the  writer's  practice  has  been  to  adopt  the  sug- 
gestion of  Zweig,  as  explained  in  a  previous  article  of  the  author,^ 
and  centrifuge  the  same  amount,  15  c.c,  of  the  well-mixed  contents 


^Boston  Med.   and  Surg.  Jour.,  1911,   77-80. 


ACQUISITION   AND   EXAMINATION   OF   GASTRIC    CONTENTS  141 

for  three  minutes  in  two  graduated  tubes,  of  which  the  average  solid 
portion  in  the  tubes  is  to  be  compared  to  the  total  volume.  If  one- 
fifth  to  one-third  is  solid — that  is,  fills  the  tube  to  less  than  the  5  e.c. 
mark — we  have  a  hypersecretion;  if  beyond  the  7^/2  c.e.  mark,  there 
is  a  lack  of  tonicity  of  the  stomach.  Strauss  employs  sedimentation 
by  gravity  only,  and  Eisner  determines  the  solids  of  the  stomach 
washing,  both  methods  requiring  much  time,  but  they  all  have  their 
weaknesses.  First,  it  is  natural  that  the  portion  left  behind  has  much 
more  solid  than  liquid  constituents,  so  that  their  relation  in  that  re- 
moved is  not  a  fair  criterion;  then,  again,  the  better  masticated  and 
digested  the  bread  is,  the  less  thick  the  layer  it  will  form,  so  that 
the  digestive  factor  enters  also.  Furthermore,  where  there  is  much 
mucus,  it  is  almost  impossible  to  drive  it  to  the  bottom  of  the  tube, 
and  it  often  has  attached  to  it  many  bread  fragments,  while,  even  if 
it  is  driven  down  with  the  solid  portion,  it  increases  the  thickness  of 
the  layer  without  having  anything  to  do  with  either  secretion  or 
motility.  Boas  has  attempted  to  detect  the  presence  of  hypersecre- 
tion by  giving  a  dry  meal  and  removing  its  contents  an  hour  later, 
when,  as  he  says,  if  the  secretion  is  normal,  there  will  be  but  a  few 
cubic  centimeters  of  content,  but  Kemp  has  demonstrated,  by  giving 
the  same  patient  the  dry  meal  and  the  Ewald,  that  there  is  prac- 
tically little  difference,  either  in  the  amount  withdrawn  or  in  the  rela- 
tive thickness  of  the  layer  formed  by  the  solid  portion.  Besides  this 
condition  of  increased  secretion  due  to  exaggerated  stimulus  of  the 
food,  we  have  a  variety,  probably  of  the  same  condition,  where  the 
secretion  continues  after  the  food  has  left  the  organ,  sometimes  called 
a  continuous  secretion.  That  brings  us  to  the  question  of  how  much 
gastric  juice  there  should  be  in  a  fasting  stomach.  This  has  been 
variously  stated  at  10-50  c.e.  Probably  the  latter  is  nearer  the  aver- 
age, and  if  with  this  increased  amount  of  fasting  gastric  juice  we 
have  stomach  symptoms,  and  after  the  test  breakfast  an  increased 
amount  withdrawn,  we  may  conclude  that  we  have  a  hypersecretion 
before  us.  It  is  beginning  to  be  more  and  more  recognized  that  this 
hypersecretion,  be  it  alimentary  or  continuous,  has  a  chronic  gastric 
or  duodenal  ulcer,  or  the  scar  following  such,  as  its  basis ;  and,  while 
we  cannot  as  yet  go  as  far  as  Mayo  and  say  that  a  nervous  hyperse- 
cretion never  exists,  still  the  more  careful  our  search  the  more  often 
w411  we  find  some  organic  change  in  the  wall  of  the  stomach  as  the 
source  of  this  secretory  excitability.  The  condition  known  as  peri- 
odic hypersecretion,  accompanied  by  migraine,  epigastric  pain,  and 
vomiting,  is  probably  only  an  exaggeration  of  the  disease  described. 


142  DISEASES   OF   THE   DIGESTIVE    TRACT 

and,  if  the  patient  is  examined  during  the  intervals,  it  has  been  the 
writer's  experience  that  a  moderate  increase  in  the  secretion  of  the 
gastric  juice  will  be  found  under  the  slight  stimulus  of  the  bread 
and  water.  Much  care  must  be  taken  to  distinguish  between  fasting 
residue  and  secretion,  which  cannot  always  be  done  at  a  glance.  The 
latter  must  present  the  following  characteristics:  it  must  be  of  the 
color  of  water  or  tinged  lightly  green,  transparent,  opalescent  or 
cloudy  from  a  few  flakes  of  mucus,  like  the  washing  of  the  mouth; 
hydrochloric  acid  is  always  present  in  amounts  from  15  to  60  and  the 
addition  of  a  few  drops  of  Lugol's  solution  should  produce  no  change 
of  color  other  than  the  yellow  of  the  iodine.  No  gas  bubbles  should 
be  present,  and  the  sediment  should  consist  of  epithelial  cells  and 
leucocyte  neuclei,  and  only  rarely  a  starch  granule.  Sarcime  and 
yeast  spores  in  chains  must  be  wanting,  and  the  solid  as  compared 
with  the  fluid  portion  must  be  less  than  one-twentieth.  The  residue 
resulting  from  stasis  will  have  some  or  all  of  the  opposite  character- 
istics, particularly  lessened  or  absent  hydrochloric  acid,  sarcinas  in 
great  numbers,  and  many  starch  remnants.  The  solid  portion  of  the 
gastric  content  may  be  '  *  well  digested ' ' — that  is,  so  flnely  divided  that 
it  looks  like  a  powder  at  the  bottom  of  the  glass — or  ' '  poorly  digested, ' ' 
when  great  bread  crumbs  are  seen,  much  as  when  bread  is  chewed  and 
spit  out,  which  latter  condition  is  often  found  in  achylia.  An  in- 
spection of  the  state  of  the  solid  portion  can  best  be  made  after  the 
content  has  stood  some  time  in  a  conical  glass,  or  by  pouring  some 
of  the  content  into  a  plate,  when  also  the  mucus  can  be  more  readily 
examined.  From  a  coarse,  slightly  comminuted  sediment  we  can 
draw  only  the  conclusion  that  gastric  digestion  is  faulty  when  masti- 
cation has  been  thorough,  for  inefficiency  in  that  act  produces  the 
same  general  appearance.  When  there  is  a  large  amount  of  hydro- 
chloric acid  present,  the  bread  is  usually  in  a  flne  powder,  unless 
there  is  considerable  mucus,  which  seems  to  protect  the  gluten  from 
the  action  of  the  gastric  juice,  when  we  may  have  the  appearance 
of  a  poorly  digested  solid  residue.  The  "three-layer"  arrangement 
of  a  content,  after  standing  for  some  time  in  a  glass,  is  very  suggestive 
of  atony  or  stasis,  and  is  made  up  as  follows :  at  the  bottom  is  a  laj'er 
of  solid  material,  then  above  this  a  layer  of  cloudy  fluid,  with  no 
food  particles,  and  at  the  top  a  layer  containing  many  gas  bubbles  and 
made  up  chiefly  of  mucus  and  some  food  particles.  The  odor  of  the 
content  also  gives  us  some  information  as  to  the  conditions  in  the 
stomach.  An  alcoholic  odor,  like  fermenting  wine  or  cider,  indicates 
an  active  fermentative  process  from  yeast;  an  unpleasant  odor,  like 


ACQUISITION   AND   EXAMINATION   OF   GASTRIC    CONTENTS  143 

that  of  rancid  butter,  means  the  presence  of  organic  acids;  and  a 
putrefactive  odor,  like  spoiled  meat,  is  associated  with  gastric  cancer 
which  is  undergoing  ulceration.  The  presence  of  sarcinee  gives  a 
musty  odor,  which  is  very  characteristic. 

Foreign  Substances. — Foreign  substances  in  the  content — like  blood, 
bile,  mucus,  pus,  and  tissue  fragments — all  lend  their  peculiar  modi- 
fication to  its  appearance.  Small  spots  or  streaks  of  fresh  blood  have 
no  significance  other  than  that  the  slight  trauma  of  the  tube  has  pro- 
duced them.  If  blood  is  present  to  any  extent,  the  color  of  the  con- 
tent becomes  dark-brown  to  blackish-brown,  or,  if  the  bleeding  has 
been  recent  and  excessive,  the  color  may  be  dark-red  to  brown.  Such 
an  appearance  usually  means  ulcer  or  carcinoma  of  the  stomach.  The 
color  may  be  yellow  to  green  if  bile  be  present,  and,  if  constantly 
present,  means  a  stenosis  of  the  duodenum  below  the  outlet  of  the 
common  duet.  The  presence  of  bile  in  the  fasting  stomach  has  no 
significance,  because  of  the  relaxation  of  the  pylorus,  which  allows  the 
duodenal  contents  to  come  through.  It  is  also  almost  universal  to 
have  the  washings  of  the  fasting  stomach  bile  tinged  for  the  same 
reason.  All  contents  which  are  green  do  not,  however,  necessarily 
contain  bile,  for  the  growth  of  a  peculiar  mold  or  algae  may  produce 
this  color,  and  the  chemical  test  clears  this  up  promptly. 

Presence  of  Mucus. — The  presence  of  mucus  has  never  been  given 
the  attention  that  it  should  have  received,  and  we  are  now  beginning  to 
learn  its  significance.  The  mucus  may  arise  from  two  sources:  first, 
that  from  the  mouth,  pharynx,  and  esophagus — the  ' '  exogenous, ' '  and, 
second,  from  the  stomach  itself — the  "endogenous."  It  is  only  the 
latter  that  has  any  significance  in  diagnosis,  for  the  former  is  almost 
invariably  present  in  greater  or  less  quantities.  Hence  it  is  very 
important  when  mucus  is  present  in  large  quantities — for  the  lesser 
are  never  pathological — to  determine  whether  it  comes  from  the  stom- 
ach. As  the  content  stands,  we  may  note  that  exogenous  mucus  rises 
to  the  surface  of  the  fluid  and  can  be  easily  removed,  while  the 
stomach  mucus  is  intimately  mixed  with  the  food  fragments.  An- 
other method  of  distinguishing  the  two  is  the  addition  of  some  stain- 
ing fluid — for  example,  brilliant  green,  0.6 ;  neutral  red,  0.3,  water, 
30.0 — when  it  will  be  found  that  the  exogenous  mucus  is  intensely 
stained,  while  the  gastric  is  lightly  stained  or  not  at  all.  In  the  wash 
water  of  the  fasting  stomach,  only  that  mucus  is  to  be  regarded  of 
gastric  origin  as  is  present  in  the  form  of  clear,  transparent  lumps, 
or  producing  a  cloudiness,  which  under  the  microscope  will  be  found 
to  be  mixed  with  epithelial  cells  from  the  stomach  or  their  peculiar 


144  DISEASES   OF   THE   DIGESTIVE   TRACT 

oval  nuclei.  AYhenever,  then,  a  considerable  amount  of  mucus  of  this 
character  is  found,  we  may  regard  the  mucous  membrane  of  the  stomach 
as  in  a  state  of  catarrhal  inflammation,  the  so-called  gastric  catarrh, 
usually  a  secondary  effect  of  passive  hyperemia,  whether  due  to  an 
insufficient  heart,  cirrhosis  of  the  liver,  or  other  causes.  The  determi- 
nation of  whether  the  amount  of  mucus  is  pathologically  increased 
is  somewhat  difficult,  and  cannot  be  done  by  pouring  the  content  from 
one  glass  to  another,  as  has  been  recommended,  or  by  examining  the 
sediment  from  the  wash  water.  E.  Schuetz  has  devised  the  simplest 
and  most  practical  way,  which  is,  after  the  mucus  swimming  on  top  of 
the  fluid  has  been  removed,  to  pour  off  the  supernatant  fluid  and  empty 
the  residue  into  a  shallow  vessel,  like  an  evaporating  dish ;  then,  with 
a  piece  of  wire  bent  like  a  hook  and  roughened  on  its  concave  surface 
with  a  file,  one  proceeds  to  hook  out  of  the  opaque  mass  fragments  of 
mucus,  and  from  their  size,  tenacity,  and  number  to  reach  an  approxi- 
mate estimation  of  the  amount;  if  abundant,  long  strings  or  bands 
can  be  pulled  out,  but,  if  scanty,  only  a  few  small  flakes.  It  has 
been  noted  that  in  ulcer  of  the  stomach  mucus  is  scanty  or  absent  in 
the  content.  Taking  this  fact  as  a  basis,  it  has  been  adduced  by 
some  that  the  absence  of  mucus,  whose  presence  is  supposed  to  pro- 
tect the  stomach  during  active  digestion,  may  be  pathological,  and 
may  be  the  cause  of  many  gastric  disorders.  In  particular  they  re- 
gard the  absence  of  mucus  as  a  cause  of  hypersecretion,  but  it  is  the 
experience  of  almost  every  one  examining  many  gastric  contents  that 
these  are  the  very  instances  where  the  mucus  is  most  abundant. 
Where  the  opposite  is  true,  it  may  be  dne,  as  A.  Schmidt  suggests,  to 
the  ease  with  which  the  normal  mucus,  is  digested  by  the  superacid 
gastric  juice.  Still,  there  is  more  than  a  question  of  digestion  in- 
volved, for  in  achylia  a  stomach,  endowed  with  the  same  muciparous 
glands,  secretes  no  mucus,  and  the  bread  crumbs  float  in  a  fluid  as 
clear  as  water. 

Food  Fragments. — Food  fragments  from  previous  meals,  especially 
when  the  test  breakfast  is  taken  fasting — that  is,  ten  to  twelve  hours 
after  the  last  meal — mean  a  considerable  degree  of  stasis.  Berry 
seeds,  fragments  of  lettuce  leaves,  and  greens  have  not  this  signfi- 
cance,  because  they  leave  even  the  normal  stomach  very  slowly. 

Tissue  Fragments. — Tissue  fragments,  in  the  writer's  experience, 
have  been  limited  to  patches  of  mucous  membrane,  usuallj^  large 
enough  to  be  detected  by  the  naked  eye,  though  their  character  may 
be  quickly  verified  by  recourse  to  the  microscope,  and  on  two  occa- 
sions fairly  large  masses  of  a  malignant  growth  have  been  detached 


ACQUISITION    AND   EXAMINATION   OF    GASTRIC    CONTENTS  145 

and  washed  out  of  the  stomach.  The  cause  of  the  former,  in  the 
writer's  opinion,  is  the  collapsing  of  the  stomach  wall  over  the  eyes 
of  the  tube  as  the  contents  flow  out,  and  the  tearing  off  of  a  small  frag- 
ment of  the  mucous  membrane  as  the  tube  is  withdrawn.  Mean- 
w^hile  some  observers  have  thought  that  injury  of  the  mucous  membrane 
of  the  stomach  by  the  tube  and  removal  of  fragments  is  especially 
prevalent  in  certain  diseases,  and  also  connect  with  this  circumstance 
the  frequency  of  small  blood  clots  in  achylia  gastrica,  declaring  that 
the  walls  of  the  organ  are  particularly  vulnerable  in  this  disease.  The 
apparent  connection  is  that  in  this  disease,  on  account  of  the  scanty 
amount  of  content  that  can  be  obtained,  which  will  practically  never 
run  through  the  tube,  too  vigorous  attempts  are  made,  by  moving 
the  tube  back  and  forth  and  inducing  the  patient  to  strain,  to  ac- 
complish this  desired  result,  with  their  consequent  injury.  AVhen 
we  are  content  with  the  few  cubic  centimeters  which  can  be  obtained 
by  pinching  the  end  of  the  tube  and  removing  it,  we  shall  see  fewer 
and  fewer  instances  of  removal  of  patches  of  mucous  membrane  and 
small  blood  clots ;  then,  too,  we  shall  have  less  basis  for  the  condition 
called  "hemorrhagic  erosion"  by  Einhorn.  The  washings  from  an 
empty  or  fasting  achylic  stomach  are,  however,  much  more  likely  to 
contain  these  patches  of  mucous  membrane  than  of  any  other  disease, 
except  cancer.  Hemmeter  and  others  have  attempted  intentionally, 
by  using  tubes  with  stiff  open  ends,  to  remove  these  fragments,  in  the 
hope  that  by  their  histological  examination  we  can  make  an  earlier 
diagnosis  of  gastric  cancer,  but  the  method  has  not  been  generally  used 
because  unsatisfactory  and  not  free  from  danger. 

Tissue  Fragments  Other  Than  Mucous  Membrane. — The  tissue 
fragments  other  than  mucous  membrane,  which  are  rarely  found,  have 
been  mentioned,  and,  if  discovered,  are  of  great  aid  in  diagnosis ;  but, 
since  they  have  been  found  by  the  writer  only  twice  in  many  hundreds 
of  examinations,  and  then  only  in  the  wash  water,  they  must  be  ex- 
tremely rare. 

CHEMICAL  EXAMINATION  OF  GASTRIC  CONTENTS. 

Chemical  examination  of  gastric  contents  is  employed  to  determine 
whether  those  constituents  found  in  a  normal  digestion  are  present, 
whether  they  are  increased  or  diminished,  and  whether  there  exist 
abnormal  substances,  the  products  of  bacterial  activity  (never  discov- 
ered in  a  normal  digestion).  This  method  of  examination,  therefore, 
affords  us  a  knowledge  of  the  secretory  and  motor  functions  of  the 


146  DISEASES   OF   THE   DIGESTIVE   TRACT 

stomach  in  question,  and  also  in  some  cases  furnishes  clear  diagnostic 
points  in  the  detection  of  certain  gastric  diseases.  In  spite  of  the 
prodigious  amount  of  literature  that  has  accumulated  on  this  sub- 
ject, what  clinicians  want  to  know  is:  (1)  Is  hydrochloric  acid  pres- 
ent and  in  what  quantities?  (2)  Are  the  ferments,  pepsin  and  ren- 
nin,  there?  (A  question  which,  in  the  author's  estimation,  can  always 
be  answered  in  the  affirmative  when  hydrochloric  acid  is  normal.) 
(3)  What  progress  has  the  starch  digestion  made?  (This  is  always 
impaired  in  hypersecretion.)  (4)  Has  the  protein  digestion  extended 
beyond  the  stage  of  peptones?  (Amino-acids  may  be  present  in 
gastric  cancer.)  (5)  Are  organic  acids  found ?  (Their  presence  indi- 
cates gastric  insufficiency  or  stasis,  due  to  pyloric  narrowing.)  (6) 
Is  there  occult  or  chemical  blood  ?  Many  a  clinician  has  asked  himself 
whether  the  answer  to  these  questions  has  sufficient  value  in  diagnosis 
to  repay  one  for  the  time  and  trouble  demanded  to  answer  them. 
Some  even  have  discarded  this  form  of  examination  altogether  and 
pronounced  it  of  no  value,  but  these  have  been  men  who  have  at- 
tempted to  rely  on  the  chemical  analysis  alone  and  have  found  them- 
selves leaning  on  a  broken  reed.  This  method  has  no  greater  value, 
taken  alone,  than  inspection,  palpation,  or  percussion,  but  in  con- 
junction with  the  latter  proves  a  very  valuable  adjunct  to  diagnosis. 
To  be  of  value,  however,  the  conditions  attached  to  the  test  breakfast 
for  chemical  examination  must  be  accurately  carried  out — ^the  time 
of  removal,  the  character  and  amount  of  the  bread  and  water,  must 
always  be  the  same,  and  it  should  be  given  during  the  morning  hours, 
for  in  the  afternoon  the  acidities  are  always  increased,  due  probably 
to  mental  influence.  Some  authorities  have  attempted  to  belittle  the 
chemical  findings  because  they  claim  that  in  the  same  individual  on 
different  days  the  acid  factors  vary,  due,  as  they  state,  to  the  layer 
formation  of  the  food  in  the  stomach  and  the  withdrawal  of  the 
content  by  the  tube  at  one  time  from  the  interior  of  the  stomach  and 
at  another  from  the  periphery,  locations  where  the  amount  of  acid 
varies.  To  these  doubting  Thomases  we  can  only  offer  the  experience 
of  E.  Schuetz,  who  found  that  in  a  large  clinic  successive  acid  deter- 
minations on  the  same  patient  differed  so  little  that  they  might  well 
be  included  in  the  realm  of  negligible  chemical  inaccuracy,  due  to 
the  more  or  less  firm  adherence  of  the  hydrochloric  acid  to  the  solid 
portions.  Lefmann,  too,  has  shown  that,  while  the  free  hydrochloric 
acid  factor  may  vary  greatly,  the  total  acidity  remains  fairly  con- 
stant, even  at  months'  intervals  in  the  same  patient. 
Detection  and  Estimation  of  Hydrochloric  Acid. — This  procedure 


ACQUISITION   AND  EXAMINATION   OP   GASTRIC    CONTENTS  147 

gives  US,  perhaps,  the  most  information  in  regard  to  the  character  and 
completeness  of  digestion  in  the  stomach,  and  hence  the  greatest  aid 
in  diagnosis.  We  must  first  recognize,  however,  that  this  acid  exists 
in  two  forms:  "free" — that  is,  ununited  to  bases  or  protein — and 
** combined,"  which  is  for  the  most  part  attached  rather  loosely  to 
protein,  but  in  such  a  way  that  it  cannot  be  detected  by  the  ordinary 
reagents  for  the  ' '  free ' '  acid.  Of  the  many,  many  reagents  suggested 
for  the  detection  of  the  presence  of  the  "free"  acid,  the  writer's  trust 
is  placed  in  three  alone:  (1)  Congo  red,  which  is  best  employed  in 
the  form  of  slips  of  paper,  much  like  the  litmus  papers,  which  can  be 
purchased,  or  prepared  by  dipping  slips  of  filter  paper  in  a  1 :1,000 
watery  solution  of  congo  red  and  allowed  to  dry.  When  a  piece  of 
this  paper  is  dipped  in  a  gastric  content  containing  "free"  hydro- 
chloric acid,  it  turns  a  more  or  less  intense  blue,  according  to  the 
amount  of  the  acid.  The  papers  should  be  renewed  after  a  few 
months,  as  they  lose  their  sensitiveness.  (2)  Dimethylamidoazobenzol 
in  0.5  per  cent  alcoholic  solution,  Toepfer's  reagent,  best  kept  in  a 
dropping  bottle  because  it  stains  the  fingers  strongly,  when  added  (a 
few  drops)  to  gastric  contents  containing  free  hydrochloric  acid, 
changes  it  to  brownish-red  or  deep-red.  Unfortunately,  both  of  these 
reagents  react  not  only  to  free  hydrochloric  acid,  but  also  to  organic 
acids  and  acid  phosphates,  so  that  their  value  is  absolute  only  when 
the  latter  are  absent.  (3)  Guenzburg's  reagent  (phloroglucin,  2.0; 
vanillin,  1.0;  alcohol,  absolute,  30.0).  When  a  few  drops  are  added  to 
an  equal  amount  of  filtered  or  decanted  gastric  contents  containing 
free  hydrochloric  acid,  in  a  porcelain  dish,  and  then  warmed  gently 
over  an  open  flame  with  care  lest  the  alcohol  take  fire,  there  arises  a 
bright-red  ring  around  the  evaporated  fluids.  This  test  is  absolute, 
and  is  not  given  by  organic  acids  or  acid  phosphates.  The  congo 
papers  are  very  sensitive  if  not  too  old,  and  will*  show  free  hydro- 
chloric acid  if  present  to  the  extent  of  only  0.01  per  cent.  The  blue 
color  shown  with  organic  acids  is  not  pure,  but  grayish-blue,  and  can 
be  easily  removed  by  dipping  the  paper  in  ether,  while  the  pure  blue 
produced  by  hydrochloric  acid  cannot  be  removed  in  this  way.  The 
Guenzburg  reagent  must  be  kept  in  a  dark  place  and  must  not  be  too 
old,  for  with  age  it  loses  its  sensitiveness.  Of  course  the  integrity  of  the 
reagent  can  be  determined  at  any  time  by  simply  heating  some  of  it 
with  a  few  drops  of  diluted  hydrochloric  acid.  Then,  again,  great 
care  should  be  taken  when  heating  that  it  does  not  char  and  assume  a 
brown  color.  The  writer's  custom  is  to  warm  until  the  first  faint  red 
ring  appears,  then  remove  it  from  the  flame  and  allow  it  to  spon- 


148  DISEASES   OF   THE   DIGESTIVE   TRACT 

taneously  evaporate  still  further,  which  it  will  do  by  means  of  the 
heat  in  the  porcelain  dish.  The  reagent  is  much  more  delicate  than 
the  Congo  red,  and  will  indicate  the  presence  of  the  acid  when  it 
amounts  to  only  0.005  per  cent.  The  mere  presence  of  free  hydro- 
chloric acid  does  not  indicate  that  secretion  is  normal;  that  can  be 
told  only  by  the  subsequent  quantitative  determination.  When  ab- 
sent, however,  under  the  conditions  mentioned,  it  may  mean  a  diminu- 
tion or  absence,  due  to  disease  of  the  glandular  parenchyma.  This 
may  be  the  result  of  atrophy  of  the  glands,  associated  with  chronic 
gastritis,  or  of  a  congenital  functional  inactivity.  The  absence  of 
free  hydrochloric  acid  is  also  a  characteristic  of  achylia,  where,-  in  ad- 
dition, there  is  also  a  lack  of  the  ferments.  In  such  cases,  too,  the 
combined  acid  is  very  much  diminished  or  entirely  wanting.  It  is 
probable  that  nervous  influences  and  the  condition  of  the  blood  may 
cause  a  suppression  of  the  hydrochloric  acid,  and  attention  has  been 
repeatedly  called  to  this  feature  in  pernicious  anemia;  in  fact,  from 
its  absence  and  the  general  cachexia  of  the  patient,  two  individuals 
in  the  writer's  experience  have  had  exploratory  operations  for  sus- 
pected gastric  cancer  before  more  careful  examination  showed  this 
malignant  disease  of  the  blood.  Another  cause  for  the  suppression 
which  has  come  to  the  writer's  attention  several  times  is  migraine, 
an  observation  which  has  been  verified  by  Kelling.  Early  pulmonary 
tuberculosis  is  also  provocative  of  suppression  of  hydrochloric  acid, 
and  in  our  student  days  under  Boas  we  were  especially  enjoined  to 
make  a  careful  examination  of  the  lungs  when  achylia  was  found.  In 
gastric  cancer  there  is  usually  no  hydrochloric  acid,  and  diagnosis  by 
chemical  aid  fell  largely  into  disrepute  for  this  reason,  because  for  a 
time  it  was  supposed  that  from  an  absence  of  free  hydrochloric  acid 
in  gastric  contents  we  could  immediately  diagnose  cancer.  We  have 
already  noted  the*  other  conditions  which  may  produce  this  suppres- 
sion, and  we  now  know  that,  when  cancer  is  engrafted  on  ulcer,  hydro- 
chloric acid  may  persist  to  the  end.  The  actual  statistics,  however, 
show  that  hydrochloric  acid  is  lacking  in  from  71  to  84  per  cent  of 
gastric  cancer,  so  that  this  feature  has  a  decided  diagnostic  value, 
though  not  absolute.  The  cause  for  this  suppression  has  been  demon- 
strated to  be  the  atrophy  of  the  secreting  glands,  accompanied  nat- 
urally with  loss  of  rennin.  The  pathological  and  the  chemical  changes 
go  on  hand  in  hand,  as  has  been  shown  by  ]\Iatti,  who  examined  the 
mucous  membrane  of  the  stomach  from  operative  cases  of  gastric 
cancer.  Others  have  attempted  to  explain  this  loss  by  the  neutraliza- 
tion of  the  acid  by  the  amino-acids  produced  by  the  action  of  a  secre- 


ACQUISITION   AND   EXAMINATION   OF   GASTRIC    CONTENTS  149 

tion  of  the  growth,  which  is  known  to  carry  the  digestion  of  protein 
beyond  the  peptone  stage.  It  has  long  been  recognized  that  growths 
at  the  fundus  of  the  stomach  suppress  the  secretion  of  hydrochloric 
acid  much  more  quickly  and  thoroughly  than  those  at  the  pylorus,  but 
this  may  be  due  to  the  more  rapid  growth  and  extensive  infiltration  of 
the  gastric  walls  by  the  former,  while  the  latter  are  slow  growing  and 
for  a  long  time  limited  to  this  locality ;  hence  some  inference  as  to  the 
site  of  the  growth  may  be  drawn  from  this  incident. 

Amount  of  Hydrochloric  Acid  Secreted.^How  much  hydrochloric 
acid  there  is,  whether  excessive  (hyperchlorhydria)  or  diminished 
(hypochlorhydria),  can  be  answered  only  by  a  careful  estimation  or 
measurement  with  an  alkali  solution  of  known  strength.  True,  we 
can  often,  from  the  intensity  of  color,  with  Guenzburg's  and  congo 
red  tests  obtain  a  rough  estimate  of  the  amount,  but,  if  we  make  a  prac- 
tice of  drawing  conclusions  as  to  the  quantity  from  the  intensity  of 
color  and  then  check  this  by  a  quantitative  determination  from  the  dis- 
parity of  these  two  factors  acquired  in  this  way,  we  shall  soon  be  will- 
ing to  follow  Lowell's  advice  in  the  Bigelow  papers,  "Don't  prophesy 
unless  you  know."  The  titration  should  be  carried  out,  if  possible, 
with  the  unfiltered  gastric  contents,  since  repeated  examinations  will 
soon  show  one  that  the  acidity  of  unfiltered  contents  is  almost  invari- 
ably greater  than  that  of  the  filtered,  the  reason  for  which  is  the 
probable  mechanical  union  of  hydrochloric  acid  with  the  undigested 
particles.  This,  too,  avoids  the  tedious  operation  of  filtering,  and,  if 
the  content  is  briskly  stirred  while  adding  the  alkali,  thorough  mixing 
takes  place.  The  greatest  difficulty  is  in  accurate  measurement,  be- 
cause the  very  convenient  measuring  pipettes  cannot  be  used,  as  their 
caliber  is  too  small.  First,  then,  after  removal  of  as  much  floating 
mucus  as  possible,  we  stir  up  the  contents  thoroughly  with  a  glass  rod, 
measure  out  10  c.c.  with  a  small  graduate  (the  graduated  sedimenta- 
tion tubes  mentioned  above  are  very  convenient)  and  pour  it  into  a 
small  beaker,  or,  on  account  of  the  white  background  for  the  observa- 
tion of  change  of  color,  a  porcelain  evaporating  dish.  Then  we  add 
to  the  contents  a  few  drops  of  Toepfer's  reagent  (dimethylamidoazo- 
benzol)  and  drop  into  it  a  one-tenth  normal  sodium  hydroxide  from  a 
burette,  first  noting  the  point  at  which  the  liquid  stands,  until  the 
red  color  has  changed  to  a  distinct  yellow  and  all  the  red  has  disap- 
peared, or  is  similar  to  the  color  of  one  drop  of  the  sodium  hydroxide 
solution.  10  c.c.  of  water,  and  a  few  drops  of  Toepfer's  reagent,  and 
again  read  the  level  of  the  fluid  in  the  burette.  The  difference  is  the 
number  of  cubic  centimeters  necessary  to  neutralize  the  free  hydro- 


150  DISEASES   OF   THE   DIGESTIVE   TRACT 

chloric  acid  in  10  c.c.  of  gastric  contents,  and  is  usually  multiplied  by 
10  to  obtain  the  amount  for  100  c.c.  of  content :  thus,  if  3.5  c.c.  were 
used  for  10  c.c.  of  content,  the  free  hydrochloric  acid  is  commonly  ex- 
pressed as  35.  Since,  however,  each  cubic  centimeter  of  the  one-tenth 
normal  sodium  hydroxide  solution  is  equivalent  to  a  cubic  centimeter 
of  a  one-tenth  normal  hydrochloric  acid  solution  containing  0.00365 
gram  of  absolute  hydrochloric  acid,  we  may  multiply  the  35  by  this 
factor  and  obtain  0.12775  gram,  or  0.12  per  cent  hydrochloric  acid. 
Instead  of  adding  Toepfer's  reagent  to  the  content,  we  may  add  the 
sodium  hydroxide  solution  directly  to  the  fluid,  and  with  a  fine-pointed 
rod  remove  tiny  portions  and  add  them  to  congo  paper  until  they  pro- 
duce blue  no  longer,  or  cause  no  more  change  in  the  paper  than  a  drop 
of  water  added  for  comparison,  the  calculation  being,  of  course,  the 
same.  The  Guenzburg  reagent  can  be  used  in  the  same  way  for  the 
end  reaction,  but  is  very  cumbersome. 

Total  Acidity. — The  total  acidity,  if  free  hydrochloric  acid  is  found, 
affords  more  information  than  the  determination  of  the  amount  of 
hydrochloric  acid,  since,  according  to  Lefmann,  under  this  condition 
it  is  made  up  chiefly  of  that  acid.  If,  however,  no  free  hydrochloric 
acid  is  present,  the  total  acidity  may  be  made  up  of  combined  hydro- 
chloric acid,  organic  acids,  and  acid  phosphates.  It  is  determined  by 
adding  to  the  same  contents  in  which  we  have  found  the  amount  of 
free  hydrochloric  acid  5  or  6  drops  of  phenolphthalein  solution  (0.5 
per  cent  in  alcohol),  and  then  letting  the  sodium  hydroxide  solution 
into  it  until  the  color  becomes  no  redder  by  the  next  successive  drop. 
The  total  acidity  must  be  measured  by  the  number  of  cubic  centimeters 
of  sodium  hydroxide  used  for  neutralization.  This  cannot  be  con- 
verted into  any  acid  as  in  hydrochloric  by  a  factor,  because,  as  stated, 
it  is  made  up  of  at  least  four  different  factors.  Therefore,  for  illustra- 
tion, if  it  took  6.4  c.c.  of  one-tenth  normal  sodium  hydroxide  to  neu- 
tralize the  acids  of  10  c.c.  of  gastric  contents,  we  say  the  total  acidity 
is  64,  meaning  64  for  100  c.c.  When  we  combine  the  determination 
of  free  hydrochloric  acid  and  total  acidity  as  here  described,  we  begin, 
of  course,  to  read  from  the  stand  of  the  fluid  in  the  burette  before  we 
begin  to  neutralize  the  free  hydrochloric.  The  quantitative  determina- 
tion of  the  combined  hydrochloric  after  a  test  breakfast  can  usually 
be  obtained  by  simply  subtracting  the  free  hydrochloric  from  the 
total  acidity,  since  acid  phosphates  are  present  only  in  the  tiniest 
amount  and  negligible,  while  organic  acids  are  never  present  with  any 
appreciable  amount  of  free  acid.  In  fact,  the  writer's  impression  from 
hundreds  of  examinations  is  that,  if  we  demonstrate  the  presence  of 


ACQUISITION   AND   EXAMINATION   OP   GASTRIC    CONTENTS  151 

free  hydrochloric  and  calculate  the  total  acidity,  we  have  learned  about 
all  that  we  can  of  the  secretory  function  of  the  stomach;  when,  on 
the  contrary,  free  hydrochloric  is  not  present,  a  much  more  careful 
examination  must  be  made,  since  the  total  acidity  may  then  be  made 
up  of  combined  hydrochloric,  acid  phosphates,  and  organic  acids. 
Many  recommend  under  these  conditions  the  determination  of  the 
hydrochloric  acid  deficit — i.e.,  the  amount  of  this  acid  needed  to  satu- 
rate all  the  protein  left  uncombined  in  the  content — since  it  is  known 
how  much  of  this  it  would  require  to  saturate  all  the  protein  that  is  in 
the  bread  taken.  This  method  of  comparing  a  known  quantity, 
amount  of  bread  eaten,  with  an  unknown  quantity,  ratio  of  bread  re- 
moved to  the  total  in  the  stomach  at  time  of  removal  (for  it  is  well 
known  that  the  whole  is  probably  never  withdrawn),  produces  such 
uncertain  results  that  little  reliance  can  be  placed  on  them.  Some 
objections  have  been  raised  to  the  use  of  phenolphthalein  because  it  re- 
acts only  to  free  alkali,  and,  furthermore,  the  alkali  combines  with  the 
proteoses  to  a  certain  extent  before  the  end  reaction  is  shown.  This 
demands  that  extreme  redness  be  produced,  but,  unfortunately,  for 
these  reasons  the  total  acidity  is  always  found  a  little  too  high.  On 
account  of  these  deficiencies,  litmus  has  been  proposed  for  the  end  re- 
action, but  comparisons  of  titrations,  using  both  phenolphthalein  and 
litmus,  show  so  little  difference  that  for  all  practical  purposes  they  are 
alike. 

Diagnostic  Significance  of  Acid  Determination. — The  diagnostic 
significance  of  acid  determinations  is  very  little  when  taken  alone  and 
not  in  connection  with  other  considerations.  Furthermore,  such  find- 
ings can  have  value  only  when  we  are  able  to  fix  well-restricted  normal 
limits,  a  feat  somewhat  difficult  because  these  acidities  seem  dependent 
on  racial  characteristics,  environment,  etc.,  but  more  particularly  on 
the  desire  of  every  clinican  to  somewhat  modify  the  test  breakfast, 
whereby  no  uniformity  of  the  stimulus  can  be  maintained,  and,  nat- 
urally, no  uniformity  of  the  results.  The  limits  within  which  an 
acidity  may  be  regarded  as  normal  will  soon  be  determined  by  every 
clinician  from  the  preponderance  of  cases  without  marked  gastric 
lesions  whose  acidities  fall  within  these  limits.  The  writer's  expe- 
rience would  place  the  limits  for  free  hydrochloric  acid  between  20 
and  40,  or  0.07  and  0.14  per  cent ;  E.  Schuetz  makes  the  limits  20  and 
60 ;  and  Zweig.  30  and  40 ;  but  the  normal  acidities  in  our  clinics  do 
not  run  to  these  extremes.  As  already  stated,  when  free  hydrochloric 
acid  is  present,  the  total  acidity  is  to  be  interpreted  simply  as  a  meas- 
ure of  the  free  and  combined  hydrochloric,  and  hence  only  under  these 


152  DISEASES   OF   THE   DIGESTIVE    TRACT 

conditions,  can  it  have  any  value  in  estimating  the  integrity  and 
activity  of  the  secretory  function  of  the  stomach.  Total  acidity,  then, 
according  to  E.  Schuetz,  ranges  from  40  to  80;  according  to  Zweig, 
from  50  to  60;  and  the  writer's  experience  from  clinic  and  private 
practice  accords  much  more  closely  with  the  latter  figures,  so  that 
less  than  20  for  free  hydrochloric  is  regarded  by  the  writer  as  a 
diminution  and  more  than  40  as  an  excess,  while  the  same  is  true  of 
total  acidities  of  50  and  70.  As  a  rule,  after  the  test  breakfast  there 
is  a  sharp  correspondence  between  the  free  acid  and  the  total  acidity, 
the  difference  usually  amounting  to  20.  This  difference  can,  how- 
ever, be  less  in  hypersecretion  because,  though  more  gastric  juice  is 
secreted,  there  is  not  a  corresponding  union  with  the  protein.  In  de- 
ficient motility,  too,  the  difference  may  be  greater  because,  on  account 
of  the  greater  delay  of  the  food  in  the  stomach,  there  is  a  more 
extensive  combination  of  hydrochloric  acid  with  protein,  a  relation 
maintained  also  when  there  is  much  mucus,  which  also  binds  the  free 
acid. 

Deficient  Secretion. — Deficient  secretion,  also  called  "subacidity," 
where  free  hydrochloric  is  less  than  20  and  total  acidity  less  than  40, 
is  associated  with  beginning  organic  disease  of  the  mucous  membrane 
of  the  stomach,  "gastric  catarrh,"  with  various  diseases  of  the  blood 
and  other  organs,  as  described  on  page  52,  as  well  as  with  many 
functional  disturbances  of  the  body  (menstruation).  The  diminution 
of  secretion  in  persons  over  50  years  of  age,  which  has  been  given  as 
an  explanation  of  the  so-called  "senile  dyspepsia,"  cannot  be  main- 
tained if  a  large  series  of  cases  be  examined,  and  in  the  writer's  expe- 
rience some  of  the  highest  acidities  are  found  in  persons  over  60,  which 
can  usually  be  explained  by  the  undue  stimulation  produced  by  insuf- 
ficiently masticated  foods.  The  lessened  secretions  so  often  attributed 
to  nervous  influences  undoubtedly  exists,  but  is  not  constant,  and,  if 
the  patient  is  frequently  examined,  such  patients  will  be  found  on 
certain  days  to  present  normal  acidities. 

Exaggerated  Secretion. — Exaggerated  secretion  with  free  hydro- 
chloric acid  present  and  a  total  acidity  of  over  70  can  be  due  to  dif- 
ferent nonpathological  causes  (such  as  excessive  use  of  meat,  alcohol, 
tobacco,  and  condiments)  as  well  as  to  pathological  conditions  (such  as 
the  early  stage  of  chronic  "gastric  catarrh"),  though  an  excessive 
amount  of  mucus  may  be  present.  Hypersecretion  also  accompanies 
gastric  ulcer,  and  often  cancer  when  arising  from  ulcer.  No  doubt, 
too,  it  may  arise  from  neurosis,  but  it  occurs  less  often  than  is  generally 
supposed,  and  to  the  writer  offers  an  incentive  for  most  careful  investi- 


ACQUISITION   AND   EXAMINATION   OF    GASTRIC    CONTENTS  153 

gation  regarding  ulcer  before  being  satisfied  with  the  diagnosis  of 
' '  nervous  hypersecretion. ' ' 

The  coincidence  of  hypersecretion  and  hyperacidity  has  been  so 
often  noted  that  most  investigators,  including  Bickel,  are  inclined  to 
believe  that  an  increased  percentile  acidity  due  to  hydrochloric  acid 
is  always  dependent  on  an  increased  secretion  of  gastric  juice  of 
normal  acidity.  True,  no  increased  amount  may  be  withdrawn,  but 
the  scanty  residue  indicates  that  the  major  part  of  the  meal,  with  its 
acid  neutralizing  qualities,  has  passed  through  the  pylorus,  leaving  a 
more  nearly  pure  gastric  juice  behind,  whose  acidity  is  known  to  be 
much  greater  than  that  of  the  ordinary  normal  gastric  content. 
Others  regard  the  amount  of  mucus  secreted  and  the  alkaline  secre- 
tion of  the  pyloric  region,  as  described  on  page  36,  as  important  fac- 
tors in  regulating  the  percentile  acidity  of  the  gastric  content.  What- 
ever may  be  its  cause,  E.  Schuetz  has  devised  a  ready  means  for  es- 
tablishing a  standard  of  comparison  in  which  the  confusing  percent- 
ages play  only  a  subordinate  part,  and  that  is  to  calculate  the  entire 
amount  of  hydrochloric  acid  in  the  gastric  content  by  multiplying  the 
total  acidity,  or  phenolphthalein  factor  if  hydrochloric  acid  be  pres- 
ent, by  the  total  quantity  of  content  removed,  and  divide  this  by  100. 
Thus,  to  use  his  illustration,  120  c.c.  of  content  with  an  acidity  of  80, 

80  X  120 
or       — ^ —  ,  gives  an  absolute  hydrochloric  acid  amount  of  96  c.c. 

one-tenth  normal  hydrochloric  acid.  A  gastric  content  exceeding  this 
total  in  acidity,  so  reckoned,  with  a  small  percentage  of  solid,  may  be 
regarded  as  belonging  to  the  group  of  hypersecretions,  no  matter  what 
its  percentile  acid  is.  Some  are  still  unwilling  to  give  up  their  former 
views  in  regard  to  hyperchlorhydria,  and  sometimes  it  does  not  ex- 
actly correspond  with  hypersecretion,  but  this  is  probably  due  to  our 
still  faulty  method  of  obtaining  the  total  content  with  the  tube.  The 
hypersecretion,  however,  is  that  form  which  should  be  regarded  as 
most  indicative  of  chronic  gastric  ulcer.  Hypersecretion,  too,  is 
marked  by  a  difference  between  free  hydrochloric  acid  and  total  acidity 
of  10  and  less,  while  impaired  motility  is  suggested  by  a  difference 
greater  than  20. 

No  mention  is  made,  beyond  this  brief  notice,  of  alizarin,  for  in  the 
writer's  experience,  after  many  examinations  of  contents  with  its  aid, 
no  assurance  has  ever  been  offered  him  that  it  really  indicates  when 
all  the  acidities  but  that  of  combined  hydrochloric  acid  have  been 
saturated.  Furthermore,  it  has  no  clinical  value  except  when  free 
hydrochloric  acid  is  absent,  and  in  this  case  titrating  with  one-tenth 


154  DISEASES   OF   THE   DIGESTIVE   TRACT 

normal  hydrochloric  acid  is  more  satisfactory,  but,  for  reasons  al- 
ready stated,  not  accurate.  Perhaps  it  is  well  to  state  that  it  requires 
20  c.c.  of  the  standard  acid  solution  to  saturate  the  protein  in  the  test 
breakfast,  and,  if  any  less  than  that  amount  is  used  for  100  c.c.  of 
content  to  produce  the  congo  reaction,  it  indicates  a  corresponding 
amount  of  combined  hydrochloric  acid,  and  we  are  not  dealing  with 
its  complete  absence.  These  determinations  of  the  acidities  do  not 
afford  diagnoses  which  one  may  read,  but  they  do  help  to  distinguish 
between  hypersecretion  and  impaired  motility,  conditions  requiring 
different  modes  of  treatment,  and  in  all  cases  indicate  whether  acid 
or  alkali  is  more  likely  to  prove  efficacious  in  treatment. 

Detection  of  Ferments. — The  detection  of  the  ferments  may  prove 
valuable  provided  no  free  or  combined  hydrochloric  acid  can  be  found, 
for,  when  the  latter  are  present,  the  former  are  always  found  in  suf- 
ficient quantities. 

Presence  of  Pepsin. — The  presence  of  pepsin  can  be  readily  de- 
tected by  placing  a  piece  of  hard-boiled  egg,  cut  thin  with  a  sharp 
knife  or  razor,  and  punched  with  a  small  hollow  key,  or  a  flake  of  fibrin 
which  has  been  previously  soaked  with  a  carmine  solution  and  thor- 
oughly washed,  into  a  test  tube  with  10  c.c.  of  gastric  contents  after 
adding  a  couple  of  drops  of  dilute  officinal  hydrochloric  acid  (10  per 
cent)  ;  this  tube  is  then  placed  in  a  brood  oven,  or  suspended  by  a 
string  passed  into  the  mouth  and  held  by  a  cork  in  a  bath  at  38°  to 
40°  C,  where  it  is  allowed  to  remain  two  hours.  The  entire  or  partial 
solution  of  the  egg  or  the  staining  of  the  fluid  red  by  the  carmine 
indicates  digestion  and  likewise  pepsin. 

Quantitative  Determination  of  Pepsin. — The  quantitative  determi- 
nation of  pepsin  is  also  a  laboratory  refinement,  and  has  no  clinical 
value  in  the  writer's  estimation,  although  the  easiest  and  most  practical 
method,  that  of  Gross,  will  be  given  here.  We  first  prepare  a  solution 
of  1  gram  pure  casein,  16  c.c.  of  25  per  cent  or  12.5  c.c.  of  31.9  per  cent 
(U.  S.  officinal)  hydrochloric  acid  and  one  liter  of  water,  which  can 
be  hastened  by  warming  on  a  water  bath.  From  this  stock  solution, 
which  can  be  kept  indefinitely  in  a  cool  place,  10  c.c.  are  placed  in 
each  of  five  or  six  tubes ;  then  into  the  tubes,  whose  contents  should  be 
warmed  to  39°-40°  C.  in  a  water  bath  or  brood  oven,  beginning  with 
0.01  c.c,  increasing  quantities  of  the  gastric  content  should  be  placed, 
so  that  the  series  shall  contain  respectively  0.01,  0.02,  0.03  c.c,  etc. 
This  can  be  readily  done  with  a  1-c.c  pipette  graduated  to  hundredths. 
These  tubes  are  then  allowed  to  remain  in  the  brood  oven  or  water  bath 
at  39°-40°  C.  for  fifteen  minutes,  when  they  are  removed  and  a  few 


ACQUISITION   AND   EXAMINATION   OP   GASTRIC   CONTENTS  155 

drops  of  a  saturated  solution  of  sodium  acetate  are  added  to  each.  In 
those  in  which  the  casein  is  undigested  a  cloudiness  to  a  perceptible 
precipitate  of  casein  will  form,  while  those  in  which  caseose  or  digested 
casein  is  found  will  show  no  cloudiness.  Normal  gastric  juice  in 
amounts  of  0.02  to  0.03  c.c.  w^ill  contain  enough  pepsin  to  digest  the 
amount  of  casein  present  in  10  c.c.  of  the  mixture.  The  pepsin  units 
into  which  these  results  are  sometimes  calculated  are  only  a  laboratory 
refinement. 

Detection  of  the  Presence  of  Rennin. — The  detection  of  the  pres- 
ence of  rennin  offers  but  little  more  evidence  of  the  integrity  of  the 
secreting  power  of  the  stomach  than  that  of  pepsin,  and  is  valuable 
only  when  hydrochloric  acid  is  absent;  in  fact,  Pawlow  insists  that 
these  ferments  are  one  and  the  same.  A  combined  qualitative  and 
quantitative  determination  of  rennin  can  be  readily  carried  out  by 
measuring  out  1  c.c.  of  filtered  gastric  contents  into  a  10-c.c.  graduate 
and  adding  water  to  the  mark  10;  then  pour  half  of  this  into  a  test 
tube  and  fill  again  to  10,  revolving  the  graduate  in  the  hands  to  thor- 
oughly mix  the  fluid ;  again,  pour  out  half  of  this  into  a  test  tube  and 
refill  to  10  until  4  tubes  are  prepared,  which  will  contain  dilutions  of 
contents,  1:10,  1:20,  1:40,  and  1:80;  now  add  to  each  5  c.c.  of  milk 
a  drop  of  1  per  cent  calcium  chloride  solution,  and  we  have  dilutions 
of  1 :20,  1 :40,  etc.  These  tubes  are  then  placed  in  a  brood  oven  or 
water  bath  for  twenty  minutes  and  then  removed.  If  rennin  is 
normal,  dilutions  of  1 :80  and  often  of  1 :160  wdll  be  found  coagulated ; 
if  diminished,  only  1 :20 ;  and  if  absent,  of  course,  none.  The  special 
advantage  derived  from  the  detection  of  both  pepsin  and  rennin  is 
that  their  secretion  is  less  under  the  influence  of  emotion  and  mental 
influences,  but,  as  we  are  recognizing  more  and  more  that  the  emo- 
tions suppress  the  secretion  of  gastric  juice  as  a  whole  and  not  any  ele- 
ment of  it,  these  distinctions  have  less  basis  for  their  existence.  Fur- 
thermore, in  pathological  conditions  of  the  stomach — achylia  from 
pernicious  anemia,  cancer,  and  chronic  gastritis — pepsin  and  rennin 
often  persist  when  the  secretion  of  hydrochloric  acid  is  wholly  sup- 
pressed. Hence  the  entire  absence  of  pepsin  and  rennin  means  an 
extensive  destruction  of  the  entire  glandular  structure  of  the  stomach. 
Lefmann's  opinion  is  that,  in  spite  of  extensive  efforts  on  the  part  of 
many  investigators  to  utilize  our  knowledge  of  the  enzymes  in  a 
clinical  way,  they  must  always  take  a  subordinate  place  in  impor- 
tance to  the  hydrochloric  acid  values.  As  has  been  stated,  the  detec- 
tion of  pepsin  has  no  value  when  hydrochloric  acid  is  present  to  any 
extent,  for  practically  all  investigators  have  found  that  quantitatively 


156  DISEASES   OF   THE   DIGESTIVE   TRACT 

they  run  side  by  side.  When,  however,  the  acid  is  wanting,  the  dis- 
covery of  pepsin  indicates  that  the  glandular  structure  of  the  stomach 
is  still,  to  a  certain  extent,  intact.  If  the  qualitative  test  for  pepsin 
is  faint  or  indistinct,  then  it  is  well  to  perform  the  quantitative  esti- 
mation. When  pepsin  cannot  be  found,  it  is  always  necessary  to  seek 
for  rennin  before  deciding  that  the  secreting  function  of  the  stomach 
is  wholly  lost,  for  the  latter  enzyme  is  much  more  persistent.  Nor 
should  we  fail  to  bear  in  mind  that  pancreatic  juice,  which  can  coagu- 
late milk,  may  come  through  the  pylorus  with  the  duodenal  contents 
and  rennin  be  discovered  in  a  pepsin-free  stomach,  particularly  in 
achylia,  when  not  an  atom  of  it  was  secreted  there.  The  fat-splitting 
ferment  of  the  stomach,  if  it  exists — and  many  still  insist  that  it  is  the 
ordinary  pancreatic  steapsin  which  has  wandered  through  the  pylorus 
into  the  stomach — has  so  far  acquired  no  clinical  significance. 

Starch  Digestion. — To  what  stage  starch  may  be  digested  may  often 
answer  the  question  of  how  much  hydrochloric  acid  is  secreted.  If  to 
filtered  gastric  contents  we  add  1  or  2  drops  of  Lugol's  solution  and 
find  the  blue  color  due  to  amidulin,  we  say  that  the  acid  is  increased ; 
if  there  is  no  color  other  than  the  yellow  of  the  iodine,  we  say  that 
the  acid  is  relatively  diminished,  because  we  know  that  0.07  per  cent 
of  mineral  acid  inhibits  the  action  of  ptyalin,  Avhile  1.2  per  cent  de- 
stroys it;  when  the  acid  is  combined  with  protein,  as  shown  by  the 
writer,^  the  digestion  of  starch  in  the  stomach  is  not  at  all  interfered 
with.  This  law  does  not  always  hold  true,  for  an  active  gastric  juice 
must  be  present  to  liquefy  the  envelope  of  gluten,  so  that  the  ptyalin 
or  animal  diastase  may  attack  the  starch.  Thus,  in  achylia  it  may  be 
possible,  on  addition  of  Lugol's  solution  to  find  the  yellow  perfect 
starch  digestion,  when  actually  the  starch  has  not  been  attacked. 
Under  normal  conditions  of  acidity  we  are  apt  to  find  the  amethyst  of 
erythrodextrin ;  meanwhile  we  may  find  normal  acidities  where  the 
color  remains  blue,  and  hyperacidities  where  the  color  is  red,  the  oppo- 
site of  what  we  should  expect.  The  apparent  reason  for  this  paradox 
is,  first,  the  difficulty  in  determining  accurately  the  amount  of  acid  in 
the  stomach,  and,  second,  the  so-called  layer  formation,  by  which 
starch  digestion  next  the  stomach  walls  is  quickly  checked,  while 
that  in  the  interior  may  be  continued  for  a  period  of  two  hours  or 
more. 

Detection  and  Measurement  of  Proteoses. — The  detection  and 
measurement  of  the  proteoses  in  gastric  contents  do  not  offer  enough 
information  that  can  be  made  clinically  available  to  pay  for  the  effort. 

^Boston  Med.   and   Surg.   Jour.,  June  29,    1899. 


ACQUISITION   AXD   EXAMINATION   OF    GASTRIC    CONTENTS  157 

This  is  a  retraction  of  views  expressed  by  the  author  ^  some  years  ago, 
based  on  many  examinations  which  appeared  full  of  promise  for  the 
measurement  of  motility,  but  did  not  materialize  on  longer  experience. 
The  detection  of  tryptophan  by  adding  bromine  water  or  bromine 
fumes  to  filtered  gastric  contents  and  the  consequent  production  of  a 
violet  color,  either  immediately  on  removal  or  after  being  kept  twenty- 
four  hours  in  a  warm  place  under  toluol,  is  very  significant  if  the  pres- 
ence of  duodenal  contents  can  be  excluded  from  the  stomach  (absence 
of  bile  pigment),  for  it  shows  that  the  digestion  of  protein  is  carried 
beyond  the  stage  of  peptone  to  that  of  peptid,  of  which  glycyltrypto- 
phan  is  one,  a  feat  that,  apart  from  trypsin  and  bacteria,  can  be  accom- 
plished only  by  the  secretion  of  a  malignant  growth,  as  Fischer  has 
shown.  In  the  writer's  clinics  this  test  is  made  a  routine  part  of  the 
examination  of  gastric  contents  when  hydrochloric  acid  is  absent,  as 
described  by  the  writer.^  The  presence  of  bile  in  the  contents  of  the 
stomach,  indicating  at  the  same  time  trypsin,  would,  of  course,  be  an 
insurmountable  objection  to  the  employment  of  it  for  the  detection 
of  tryptophan. 

Fatty  Acids. — The  fatty  acids,  chiefly  acetic  and  butyric,  give  a 
rancid  odor  to  gastric  contents,  and  if,  on  warming  the  contents,  a 
piece  of  blue  litmus  paper,  moistened  with  w^ater,  is  held  over  them, 
the  paper  will  redden  on  account  of  the  fumes  thrown  off.  They  have 
no  significance  beyond  indicating  that  there  is  a  certain  degree  of 
stasis. 

Lactic  Acid. — Lactic  acid  has  much  more  significance  if  no  meat — 
whose  inherent  lactic  acid  may  be  extracted  to  such  an  extent  that  it 
readily  gives  the  reaction- — is  present  in  the  gastric  contents.  Of 
diagnostic  value  is  only  the  fermentative  lactic  acid  obtained  from  car- 
bohydrates, which,  according  to  Boas,  is  produced  solely  by  the 
"thread"  or  long  bacilli.  For  reasons  mentioned,  gastric  contents  in 
w^hich  meat  fragments  are  found  are  not  suitable  for  examination  for 
lactic,  nor  are  the  washings  of  the  stomach  after  the  evening  Riegel 
meal,  but  after  the  stomach  is  well  w-ashed  out  the  presence  of  lactic 
acid  in  the  gastric  contents  of  the  test  breakfast  following  is  very  sug- 
gestive. Perhaps  in  this  case,  since  the  acid  is  produced  in  stagnating 
contents,  it  is  well  to  wait  two  or  three  hours  before  their  removal. 
As  the  activity  of  the  bacilli  is  inhibited  by  0.02  per  cent  of  hydro- 
chloric acid,  it  is  unnecessary  to  look  for  lactic  acid  when  hydro- 
chloric acid  is  frankly  present.  Some  breads  also  may  have  a  trace 
of  lactic  acid,  so  that,  where  it  is  found  in  the  contents,  it  is  well  in  a 

1  Med.  yews,  Ixxvii,  806.  2  Med.  Record,  Aug.  19,  1911. 


158  DISEASES   OF    THE   DIGESTIVE   TRACT 

watery  extract  of  the  same  bread  to  employ  the  test.  Lactic  acid  can 
"be  best  detected  by  adding  a  drop  of  1  per  cent  ferric  chloride  to  each 
of  two  test  tubes  of  like  caliber  filled  with  water,  emptying  the  solu- 
tion and  again  filling  with  water,  when  the  desired  dilute  solutions 
can  be  obtained,  to  one  of  which  a  few  drops  of  the  filtered  gastric 
content  are  added,  while  the  other  serves  as  a  control.  Placed  over  a 
white  surface  and  looked  at  along  the  length  of  the  column  of  fluid, 
the  tube  containing  the  gastric  contents  has  a  bright  canary-yellow 
color  if  lactic  acid  be  present.  The  reaction  can  be  made  sharper  by 
adding  to  each  tube  a  few  drops  of  4  per  cent  carbolic  acid,  accord- 
ing to  Uffelmann,  or  until  an  amethyst  color  is  produced,  whereupon 
the  gastric  contents  are  added  in  the  same  way.  Of  course  the  change 
from  amethyst  to  yellow  is  much  more  distinctive,  for  the  iron  solution 
always  assumes  a  dull  yellow,  which  rapidly  darkens  on  exposure  to 
air,  so  that  results  must  be  determined  at  once.  Unfortunately,  at 
times  the  gastric  contents  present  a  yellow  color,  which  makes  the  test 
very  confusing,  and  in  this  case  it  is  better  to  extract  some  of  the 
filtrate  with  a  little  ether  and  use  the  ethereal  extract  for  the  test. 
This  can  be  readily  done  with  a  test  tube  and  the  thumb  for  a  stopper, 
and  is  greatly  aided  by  adding  a  drop  or  two  of  phosphoric  acid  before 
the  extraction.  Apart  from  the  bread  mentioned  above,  we  must 
carefully  inquire  whether  the  patient  has  recently  (within  twelve 
hours  where  stasis  is  probable)  eaten  cheese,  cabbage,  cucumbers, 
grapes,  apples,  or  lemons,  or  drunk  milk  or  wine,  all  of  which  contain 
either  lactic  acid  or  an  acid  which  will  give  the  same  reaction.  Tar- 
taric acid,  too,  as  it  is  used  in  the  effervescent  mixture,  will  also  give 
this  reaction,  and  the  test  breakfast  should  not  follow  the  inflation. 
Many  of  these  precautions  were  unknown  to  the  writer  several  years 
ago  when,  in  a  published  investigation  ^  of  a  purely  protein  test  meal, 
attention  was  called  to  the  frequency  of  lactic  acid  and  doubts  were 
expressed  as  to  its  diagnostic  significance,  but  it  is  apparent  that  none 
of  the  precautions  mentioned  can  be  safely  neglected. 

Significance  of  Lactic  Acid. — The  significance  of  lactic  acid  is  that 
the  hydrochloric  acid  is  very  much  diminished  and  that  there  is  stag- 
nation of  gastric  contents.  As  these  conditions  occur,  however,  most 
frequently  in  gastric  cancer,  lactic  acid  has  come  to  be  regarded  as  an 
almost  pathognomonic  for  that  disease,  an  importance  which  never 
should  have  been  given  to  its  presence.  On  account  of  the  numerous 
sources  of  error,  the  actual  presence  of  the  ''long"  bacilli  which  pre- 
cede the  formation  of  the  acid,  either  in  gastric  contents  or  in  the 

1  Boston  Med.  and  Snrg.  Jour.,  cxliii,   1913,  467. 


ACQUISITION   AND   EXAMINATION   OF    GASTRIC    CONTENTS  159 

feces,  is  of  vastly  more  importance.  It  occurs  to  one  at  once  that 
only  when  the  malignant  disease  is  at  the  pylorus,  or  extends  to  that 
organ,  are  the  conditions  for  the  production  of  lactic  acid  (absence  of 
hydrochloric  acid  and  pyloric  narrowing)  ideal,  perhaps  due  to  the 
uneven  surface  of  the  growth  or  perhaps  to  the  blood  present,  and 
this  is  generally  true,  although  one  case  has  occurred  in  the  writer 's 
practice  where  the  growth  as  determined  by  operation  was  at  the  lesser 
curvature  and  the  pylorus  was  not  involved,  yet  moderate  stasis  and 
lactic  acid  were  present.  When  all  these  precautions  are  observed, 
lactic  acid  is  practically  never  found  except  in  malignant  disease  of 
the  stomach.  Stastistics  show  that  different  observers  have  found 
that  84  to  95  per  cent  of  all  cases  where  lactic  acid  is  present  have 
cancer,  while,  on  the  contrary,  on  account  of  the  different  sites  many 
cases  of  cancer  have  no  lactic  acid. 

Presence  of  Occult  Blood.^ — The  presence  of  occult,  or,  as  some 
■choose  to  call  it,  "chemical  blood" — that  is,  what  is  not  visible  to  the 
naked  eye,  but  can  be  detected  by  reagents  in  gastric  contents — on 
account  of  the  ease  with  which  the  mucous  membrane  can  be  injured  by 
the  tube  and  a  tiny  hemorrhage  follow,  is  of  practically  little  value, 
but  does  possess  great  importance  when  detected  in  feces,  and  hence 
the  discussion  of  the  test  will  be  deferred  to  the  next  chapter. 

Salomon  Test. — The  Salomon  test  has  also  been  employed  in  the  de- 
tection of  early  gastric  cancer,  but  the  hopes  held  out  by  its  originator 
have  not  been  justified.  It  was  based  on  the  amount  of  protein  ma- 
terial found  in  the  washings  of  the  fasting  stomach  as  determined  by 
the  Esbach  albuminometer.  The  stomach  was  to  be  washed  out  at 
■evening  and  again  the  next  morning  with  400  c.c.  of  physiological  salt 
solution,  and  when  the  albumen  content  in  the  solution,  as  measured 
by  the  instrument  mentioned,  rose  above  0.1-0.5  of  a  part  per  thou- 
sand, the  patient  was  strongly  suspected  of  having  cancer.  R.  Schmidt 
well  remarks  that,  as  a  positive  result  rests  on  a  serous  discharge  of 
the  growth,  it  may  be  as  well  given  by  ulcer,  chronic  gastritis,  and 
•even  swallowed  saliva,  while  in  his  experience  it  has  proven  negative 
in  advanced  cases  of  true  cancer.  The  writer's  own  experience  is 
limited  to  always  testing  the  morning  washings  of  the  fasting  stomach 
without  the  evening  cleansing,  which,  in  an  ambulatory  clinic  such  as 
the  writer's,  is  very  difficult  to  carry  out,  but  the  results  have  never 
been  such  as  to  convince  him  that  the  method  has  a  practical  diag- 
nostic value.  It  seems  to  the  writer  that  the  positive  outcome  of 
the  test  is  coincident  with  the  so-called  "minimal  retention,"  which, 
as  has  been  proven  by  the  experience  of  all,  is  not  to  be  necessarily  as- 


160 


DISEASES   OF   THE   DIGESTIVE   TRACT 


soeiated  with  cancer.  With  the  biological  tests  other  than  the  split- 
ting of  glyeyltryptophan,  which  has  been  described,  the  writer's  expe- 
rience is  nil,  and  until  their  technic  is  much  simplified  they  will  be  im- 
practicable for  the  use  of  the  clinic,  nor  have  their  results  been  such 
as  to  invite  extensive  use. 


MICROSCOPIC  EXAMINATION. 

The  microscopic  examination  of  gastric  contents  includes  a  search 
for  food  particles,  red  and  white   (pus)   blood  corpuscles,  epithelial 


Fig.  25. — Food  particles,     a,  starch  granules;   b,  gluten   structure;   e.  meat  tibers  with  and 
without  striation;  d,  fat  in  needles  and  globules;  e,  vegetable  residue.      (E.  Schuetz.) 

cells  and  their  nuclei,  yeast  spores,  bacilli,  and  tissue  fragments.  This 
method  is  placed  last,  not  because  it  is  less  important  under  certain 
conditions  (stasis  and  minimal  retention),  but  because  in  the  majority 
of  cases,  with  normal  motility  of  the  stomach,  nothing  can  be  learned 
from  it  beyond  what  can  be  learned  from  the  means  already  mentioned, 
and  it  is  not  made  a  part  of  the  routine  examination.     This  examina- 


ACQUISITION   AND   EXAMINATION   OF   GASTRIC    CONTENTS  16l 

tion  may  be  made  either  on  the  content  of  the  digesting  or  fasting 
stomach,  or  better,  on  the  wash  water  of  the  latter,  since  it  is  not  al- 
ways possible  to  obtain  material  from  it  with  the  tube  alone.  When 
pathological  elements  are  present  in  the  stomach,  they  will  appear  in 
the  contents  after  a  test  breakfast,  but  so  obscured  by  the  abundance 
of  food  particles  that  they  require  special  care  for  their  detection.  In 
the  wash  water  it  is  a  different  matter,  and  by  sedimentation  and 
centrifugation,  as  described  on  page  138,  we  are  enabled  to  obtain  a 
most  desirable  sediment  for  this  purpose. 

After  the  test  breakfast  or  the  evening  meal,  when  stasis  is  pres- 
ent, there  will  be  found  in  the  content  or  the  wash  water,  respectively, 
round  or  oval  starch  granules,  usually  with  the  concentric  lines,  when- 
there  is  sufficient  hydrochloric  acid,  or  without  them  when  the  acid  is 


f'> 

^ 

^^ 

% 

a. 

-h 

o 

d 

-' 

Fig.   26. — Pathologic   indications,     a,   epithelium  from  the  gastric  mucous  membrane;    &, 
leucocytes;  c,  leucocytes  embedded  in  mucus;  d,  mucous  spirals.      (E.  Schuetz). 

diminished  or  lacking.  On  the  addition  of  a  drop  of  Lugol's  solution 
these  granules  become  blue  if  hydrochloric  acid  is  present  in  normal 
amounts,  but  yellowish  if  the  acid  is  deficient.  In  contents  which 
are  poor  in  hydrochloric  acid  the  gluten  which  contains  the  starch 
granules  may  often  be  seen  in  the  form  of  net -like  masses.  The  pres- 
ence of  all  other  elements,  if  the  test  breakfast  were  taken  fasting, 
points  to  retention,  unless  possibly  a  few  fat  globules,  which  may  be 
derived  from  that  often  added  to  bread,  and  various  fragments  of 
plant  structures.  Among  these  evidences  of  retention  are  to  be  re- 
garded the  meat  fibers,  whose  well-retained  striations  are  also  indica- 
tive of  lacking  digestion.  Only  an  abundance  of  fat  after  either  meal 
is  to  be  regarded,  for  reasons  mentioned,  as  evidence  of  stagnation. 

Epithelial  cells  are  very  common,  consisting  of  large  pavement  cells 
from  the  mouth  and  pharynx,  which  have  no  interest  for  us,  and  the 
cylindrical  cells,  with  their  smaller  oval  nuclei  (Fig.  26,  a),  often  only 
a  group  of  the  nuclei  embedded  in  mucus,  the  bodies  of  the  cells  having 
been  digested. 


162  DISEASES   OF    THE   DIGESTIVE   TRACT 

Red  Blood  Corpuscles. — Red  blood  corpuscles  and  leucocytes  are  of 
little  significance  if  only  a  few  specimens  are  present.  The  former  are 
almost  invariably  found  when  the  tube  is  used,  and  the  latter  come 
from  the  posterior  nares  or  pharynx.  When  the  hydrochloric  acid  is 
scanty,  the  body  of  the  cell  remains,  but,  when  normal  or  abundant, 
only  the  nuclei  are  left  after  the  digestion  of  the  body  and  are  usually 
in  groups  of  three  or  four  embedded  in  mucus  (Fig.  26,  a).  It  is 
sometimes  rather  difficult  to  distinguish  between  the  nuclei  of  the 
pavement  cells  after  digestion  of  the  body  and  the  leucocytes  before  di- 
gestion of  the  body,  but,  if  we  remember  that  both  are  digested  simul- 
taneously and  that,  if  we  come  across  the  nuclei  of  the  digeste4  pave- 
ment cell,  we  must  necessarily  find  the  multiple  nuclei  of  the  leucocyte 
without  body,  we  shall  make  no  error. 

MICROORGANISMS. 

The  microorganisms  found  of  importance  are  usually  restricted  to 
yeast  spores,  sarcinag,  and  the  long  or  "thread"  bacilli.  The  yeast 
spores  are  always  found  in  contents,  but  gain  significance  only  when 
found  in  long  chains  or  in  groups,  and  then  indicate  stagnation  in  the 
stomach.  Their  growth  is  not  restricted  by  free  hydrochloric  acid,  and 
they  may  be  found  very  numerous  in  hyperacid  contents. 

Sarcinse. — The  sarcinae  appear  in  groups  of  four,  sixteen,  and  sixty- 
four,  like  bales  of  cotton,  or  rarely  single  (Fig.  27,  a),  in  conjunction, 
with  yeast  and  free  hydrochloric  acid.  They  signify  a  marked  degree 
of  stagnation,  usually  due  to  pyloric  stenosis,  which  is  often,  but  not 
always,  benign.  Of  the  bacilli,  the  thread-like  forms  possess  the  only 
real  diagnostic  value,  and  a  thick  bacillus  is  sometimes  described  as 
present  in  putrefactive  processes  associated  with  cancer,  but  they  have 
never  been  observed  by  the  writer.  The  "thread"  bacilli  are  prob- 
ably the  producers  of  lactic  acid,  and  have  been  variously  named  the 
Boas-Oppler,  lactic  acid,  and  long  bacilli.  Their  association  with  this 
acid  is  undoubted — whether  as  cause  or  effect  is  not  fully  known. 
They  assume  zigzag  and  whiplash  shapes,  and  to  be  of  importance 
must  exist  in  large  numbers  and  not  in  isolated  examples.  The  sig- 
nificance of  the  presence  of  numerous  long  bacilli  is  much  that  of 
lactic  acid  (absence  of  hydrochloric  acid  and  stagnation  of  gastric 
contents) ,  and,  as  these  conditions  occur  most  frequently  with  pyloric 
stenosis,  due  to  malignant  growth,  their  presence  has  come  to  bear  the 
more  liberal  and  partially  unjustified  interpretation  of  gastric  cancer. 
K.  Schmidt  has  summed  up  the  diagnostic  value  of  the  ' '  thread ' '  bacilli 


ACQUISITION    AND   EXAMINATION   OF   GASTRIC    CONTENTS 


163 


in  several  postulates,  which  are  here  given:  (1)  The  absence  of  these 
organisms  cannot  be  utilized  as  contraproof  to  the  existence  of  cancer, 
which  may  go  on  to  a  fatal  termination  without  their  presence. 
(2)  The  growth  of  this  group  of  organisms  varies  largely  in  intensity 
in  the  stomach,  but  is  much  more  even  in  the  feces,  where  it  is  always 
found    when    present    in    the    stomach,    and    sometimes    even    more 


Fig.   27 


-Microorganisms,      a,  b,  sarcinae  in  bales  and  clumps;   c,  d,  e,  yeast  spores,  sing 
in  chains,  and  in  groups;  /,  long  ("thread")  bacilli.      (E.  Schuetz.) 


luxuriantly.  (3)  Only  rarely  are  the  bacilli  found  in  the  feces  when 
not  of  gastric  origin  (Schmidt  has  seen  one  case  of  lymphosarcoma 
of  the  duodenum  and  one  of  tuberculous  stricture  of  the  lower  ileum, 
and  one  of  annular  carcinoma  of  the  descending  colon  has  been  seen 
by  the  author).  (4)  The  presence  of  a  vigorous  growth  of  these 
bacilli  in  the  gastric  contents  comes,  with  rare  exceptions,  only  in 


164  '        DISEASES   OF   THE   DIGESTIVE   TRACT 

case  of  cancer.  (5)  In  noncareinomatous  disease  of  the  stomach  they 
have  been  found  in  only  three  cases — callous  narrowing  of  the  pylorus 
due  to  acid  poisoning,  cancer  of  the  gallbladder,  and  callous  pyloric 
stenosis  due  to  a  renal  tumor,  in  all  of  which  cases  there  was  "coffee- 
grounds"  vomiting.  (6)  Isolated  examples  of  "thread"  bacilli,  espe- 
cially in  sepsis  and  peritonitis,  do  not  possess  any  diagnostic  value. 
(7)  The  absence  of  the  bacilli  with  " coff eegrounds "  vomiting  (present 
in  hypersecretion,  benign  pyloric  stenosis,  gastric  crises,  intestinal 
stenosis,  peritonitis,  and  blood  stasis  catarrh)  can  generally  be  utilized 
against  the  existence  of  cancer.  The  microscopic  examination  of  the 
sediment  from  the  stomach  washings  forms  a  most  satisfactory  method 
of  detecting  stasis,  and  the  objects  found  may  vary  from  a  few  rice 
grains  to  a  specimen  of  all  the  objects  already  mentioned.  As 
previously  stated,  the  presence  of  a  few  rice  grains  may  occur  in  a 
stomach  with  normal  motility,  but  any  considerable  number  of  these, 
accompanied  by  fat  or  muscle  fibers,  indicate  a  considerable  degree  of 
stasis.  Whenever  isolated  examples  of  the  lower  organisms — sar- 
cinae,  yeast  fungi,  and  "thread"  bacilli — are  found  in  the  gastric  con- 
tents following  the  test  breakfast,  the  washings  of  the  fasting  stomach 
are  likely  to  show  these  objects  in  large  numbers.  This  is  particularly 
true  of  the  bacilli,  and  hence  the  microscopic  examination  of  the  fast- 
ing contents  or  the  wash  water  assumes  a  great  diagnostic  value. 
When  the  wash  water  of  the  fasting  stomach  constantly  contains  meat 
fibers,  fat,  starch  granules,  and  yeast  spores  in  groups,  or  sarcinje,  we 
are  justified  in  our  conclusion  that  there  is  a  marked  gastric  insuf- 
ficiency, and,  if  these  objects  are  present  in  large  numbers,  that  there 
is  a  pyloric  narrowing.  At  least,  when  washing  fasting  stomachs,  we 
should  never  rely  on  the  unaided  eye  alone  to  determine  the  presence 
of  residue,  but  apply  the  microscope. 

Many  methods  have  been  suggested  for  testing  the  functions  of 
the  stomach  without  the  aid  of  the  sound — the  pearl  tests  of  E inborn, 
the  desmoid  test  of  Salili,  the  soda  test  of  Fuld,  for  the  detection  of 
free  hydrochloric  acid  mentioned  on  page  103,  and  the  connective 
tissue  test  of  A.  Schmidt.  Of  all  of  these  only  the  last  has  been  of 
any  aid  to  the  writer,  and,  as  described  in  his  article,^  that  also  hais 
left  the  writer  in  the  lurch,  and  Schmidt  himself  has  been  obliged  to 
modify  his  original  statement  that,  where  abundant  connective  tissue 
appears  in  the  stool  after  100  grams  of  chopped  meat,  slightly  cooked, 
is  taken  daily  by  the  patient  for  three  days,  it  indicates  absence  of  or 
marked  diminution  of  the  hydrochloric  acid  of  the  stomach.     Hence, 

1  Boston  Med.  and  Surg.  Jour.,  clxiv,  10. 


ACQUISITION   AND   EXAMINATION   OF    GASTRIC    CONTENTS  165 

as  none  of  these  have  proven  themselves  practicable  after  being  thor- 
oughly tested,  and  have  been  the  source  of  much  discussion  and  largely 
unfavorable  comment,  they  will  not  be  given  here.  The  detection 
of  numerous  sarcinae  in  the  feces  points  directly  to  gastric  stasis,  due 
to  pyloric  stenosis,  and  indicates  that  hydrochloric  acid  still  persists, 
which  stenosis  may,  of  course,  be  benign,  or,  as  explained,  due  to  malig- 
nant disease  in  an  early  stage. 


CHAPTER  VI 

EXAMINATION  OF  FECES 

The  character  of  the  feces  depends,  of  course,  on  the  nature  of  the 
food,  and  we  can  compare  the  feces  of  two  individuals  only  when 
they  are  both  taking  the  same  food  in  approximately  the  same  amounts. 
Under  pathological  conditions  the  influence  of  the  food  becomes  still 
more  prominent  because,  on  account  of  impaired  absorption,  much 
more  food  residue  of  one  or  all  classes — fat,  protein,  and  starch — ap- 
pears in  the  feces.  Furthermore,  the  desquamative  products  of  the 
intestinal  mucous  membrane — epithelial  cells  and  mucus — which, 
under  normal  conditions  are  barely  perceptible,  begin  to  form  a  con- 
siderable part  of  the  mass  of  the  feces.  When  the  choice  of  food  is 
left  to  the  patient's  whim,  so  many  foreign  and  bizarre  structures  of 
varied  vegetable  origin  appear  that  those  most  widely  familiar  with  the 
microscopic  appearance  of  feces  are  often  puzzled.  Hence,  since  the 
establishment  of  the  character  of  a  "normal  feces"  dependent  on  a 
constant  diet  has  been  established  largely  through  the  labors  of  A. 
Schmidt  and  Strassburger,  we  have  followed  very  closely  the  test  diet 
prescribed  by  the  former.  This  diet  has  no  merits  above  any  other 
which  any  clinician  may  devise  for  himself,  except  that  he  must  first 
examine  the  feces  of  many  hundreds  of  normal  individuals  on  his  own 
diet,  work  which  has  already  been  performed  by  Schmidt  on  the 
diet  usually  named  after  him.  Now,  apart  from  this  advantage,  we 
find  that  this  diet  is  suitable  not  only  for  healthy  individuals,  but  can 
be  borne  by  those  who  do  not  have  a  sound  intestinal  tract ;  that  it  is 
sufficient  in  calories  for  the  sustenance  of  every  patient,  and  that  it 
contains  the  three  groups  of  food  elements — carbohydrates,  fat,  and 
protein — in  the  right  proportion.  The  author  suggested  a  diet  to  be 
followed  for  a  strictly  quantitative  chemical  examination  of  feces,^ 
but  the  diet  proved  too  monotonous  and  the  chemical  examination  too 
cumbersome  for  clinical  work,  so  that  in  recent  years  recourse  has 
always  been  had  to  the  Schmidt  diet  and  the  microscopic  or  micro- 
chemical  examination  of  feces.  The  objections  often  offered  to  the 
Schmidt  diet  are  that  it  contains  too  much  milk,  borne  badly  by  some 

»  Phila.   Med.   Jour.,   Sept.   22,    1900. 

166 


EXAMINATION   OF   FECES  167 

patients,  and  that  its  use  becomes  obnoxious,  but  the  author's  chief 
difficulty  has  been  that  with  many  patients  it  was  too  copious  and  they 
declared  it  was  physically  impossible  to  ingest  the  amounts  given.  In 
such  diseases  as  appendicitis  and  intestinal  stenosis  it  is  not  well  to 
employ  the  diet,  and  possibly  in  other  conditions,  until  an  examina- 
tion of  the  stool  with  the  often  faulty  diet  indulged  in  when,  after 
the  Schmidt  diet  is  employed,  it  is  sometimes  surprising  to  see  marked 
changes  for  the  better  from  the  diet  alone — movements  previously 
induced  only  by  laxatives  become  spontaneous  and  mucus  largely 
disappears.  A  well  known  professor  in  a  leading  university  used  to 
remark  that  the  only  thing  for  which  he  was  noted  was  that  he  had 
never  devised  a  modification  of  Tarnier's  forceps,  so,  also,  few  are  dis- 
tinguished for  not  having  modified  the  Schmidt  diet,  but  the  one  given 
here  is  only  somewhat  changed  to  avoid  the  five  meal  schedule,  diffi- 
cult for  our  people  to  carry  out,  while  express  permission  is  given 
by  the  originator  to  make  this  change : 

DIET  LIST  FOR  TESTING  INTESTINAL  FUNCTIONS. 

Breakfast, — A  large  cup  or  bowl  of  tea  or  coifee,  half  milk;  a  roll, 
with  butter;  a  large  saucer  of  oatmeal,  with  cream  and  sugar,  if  de- 
sired; and  a  soft-boiled  egg.  (It  is  better  to  sift  the  oatmeal  through 
a  sieve  before  cooking.) 

Dinner. — A  large  portion  of  Hamburger  steak,  cooked  with  butter, 
but  so  prepared  that  the  interior  shall  be  rare  (^  pound  should  be 
eaten)  ;  and  at  least  4  tablespoonfuls  of  mashed  potato,  also  passed 
through  a  sieve. 

Midafternoon. — A  roll  well-buttered,  and  a  large  cup  of  tea  or  cocoa, 
half  milk. 

Supper. — A  roll  or  slice  of  toast,  with  butter ;  a  large  glass  of  milk ; 
and  two  eggs  scrambled,  with  butter. 

The  patient  may  drink  as  much  water  as  is  desired  between  meals. 
This  diet  is  to  be  continued  for  three  days,  and  on  the  fourth  morning 
the  stool  is  to  be  saved  in  a  Mason  jar.  If  the  bowels  do  not  move 
daily,  use  a  plain  injection  of  water,  but  no  laxatives.  The  dinner 
here  given  and  the  supper  may  be  interchanged. 

When  the  stool  is  first  seen  in  the  j\Iason  jar  (or  any  other  fruit  jar 
which  can  be  tightly  sealed),  we  note  first  whether  it  is  solid,  semi- 
solid, or  liquid,  whether  it  is  dark  or  black  in  color  (iron,  bismuth, 
or  digested  blood),  normal  color  or  colorless  (gray,  clayey,  etc.), 
whether  any  mucus  may  be  adherent,  and  whether  fresh  blood  streaks 
are  found  upon  it.     If  colorless,  a  bit  of  the  feces  may  be  mixed  in 


168  DISEASES   OF   THE   DIGESTIVE   TRACT 

a  test  tube  with  alcohol,  the  alcohol  poured  off  or  filtered,  and  the 
Ehrlich  aldehyde  reagent  added  (dimethylamidoazobenzolaldehyd,  2.0, 
and  acid  hydrochloric  concentrated,  100.0).  Then  a  pinch  of  pow- 
dered thymol,  which  destroys  all  odor,  is  added  to  the  stool  in  the 
jar,  water  is  then  poured  into  it,  and  with  an  egg  beater  that  will 
enter  the  jar  the  whole  is  made  into  a  homogeneous  mixture.  Into 
this  a  piece  of  litmus  paper  is  dipped  and  the  reaction  determined, 
when  often  small  fragments  of  partially  digested  mucus  (frog  spawn) 
eome  to  light,  swimming  on  the  fluid,  or  fragments  of  connective  tis- 
sue. Our  examination  may  be  very  much  facilitated  by  pouring  out 
some  of  the  mixture  into  a  soup  plate,  blackened  on  its  inner  sur- 
face. Then  from  this  mixture  three  drops  are  to  be  placed  on  as 
many  glass  slides,  or,  for  rapid  work,  a  tiny  fragment  of  the  original 
stool  may  be  smeared  on  a  slide  and  well  rubbed  with  a  drop  of  water, 
cover  glasses  placed  over  them,  and  the  redundant  fluid  removed  by 
fllter  paper.  One  slide  is  to  be  examined  under  the  microscope  di- 
rectly; the  second  to  have  a  drop  of  Lugol's  solution  (iodine,  1.0; 
potassium  iodid,  2.0;  distilled  water,  50),  for  distinguishing  starch 
residue,  placed  alongside  the  cover  glass,  when,  by  capillary  attrac- 
tion, everything  underneath  is  uniformly  stained ;  while  the  third 
is  to  be  treated  with  a  drop  of  a  watery  solution  of  nile  blue  sulphate 
for  distinguishing  neutral  fat,  fatty  acids,  and  alkaline  soaps.  Then, 
with  the  "mucus  hook,"  described  on  page  144,  we  fish  out  any  frag- 
ments which  resemble  mucus  or  connective  tissue,  which  in  small 
fragments  cannot  be  distinguished  by  the  naked  eye,  and  place  such 
a  fragment  on  a  slide,  cover  with  a  cover  glass,  as  before,  and  add  a 
drop  of  the  "brilliant  green-neutral  red"  solution,  described  on  page 
143,  alongside  of  the  cover,  and  examine ;  then  the  liquid  mixture  may 
be  poured  through  a  sieve  for  the  detection  of  gallstones  or  tapeworm 
fragments.  For  the  test  for  occult  or  chemical  blood,  which  will  be 
described  later,  this  diet  is,  of  course,  unsuitable  on  account  of  the 
meat,  and,  if  there  is  any  suspicion  of  ulcerous  processes  in  any  part 
of  the  entire  tract,  the  patient  should  take  a  good  dose  of  castor  oil 
(20  c.c),  refrain  from  meat,  fish,  soup,  or  beef  extract  for  three  days, 
and  then  collect  the  stool  for  the  blood  test.  If  eggs  or  cheese  be 
substituted  for  the  meat  in  the  Schmidt  diet,  the  stool  serves  very 
well  for  the  determination  of  intestinal  function  and  detection  of 
blood,  except  that  we  learn  nothing  about  the  digestion  of  meat.  At 
least,  before  a  positive  reaction  for  chemical  blood  is  accepted,  the 
patient's  statement  that  no  meat  has  been  taken  must  be  verified  by 
a  search  for  meat  fibers  with  the  microscope. 


Fig.  28.— Microscopic  appearance  of  normal  stool  on  test  diet,  a,  muscle  fiher  rem 
nanfs;  b,  yellow  lime  soaps;  c,  white  lime  soaps;  d.  epidermal  grain  fragments;  e.  empty 
potato  cells;  /,   detritus;   y,  cocoa  residue.      (A.    Schmidt.) 


Fig.  29. — Gross  appearance  of  stool  containing  excess  of  connective  tissue. 


EXAMINATION  OF  FECES  169 

GENERAL  CHARACTERISTICS. 

General  eharaeteristics  of  the  feces  first  include  the  amount,  which 
in  normal  individuals  on  this  test  diet  reaches  oh  the  average  251 
grams  daily,  of  which  21  per  cent  is  solid.  The  enormous  increase,  in 
certain  diseases  of  the  organs  associated  with  intestinal  digestion,  as 
well  as  of  the  intestine  itself,  can  be  seen  in  the  following  figures: 
fermentative  dyspepsia,  770  grams;  achylia  gastria  with  diarrhea, 
527.5;  closure  of  common  duct,  944;  suppressed  pancreatic  juice, 
2868,5;  severe  enteritis,  2,780.  On  the  contrary,  in  persons  who  are 
constantly  constipated  the  daily  amount  of  feces  is  much  diminished 
— often  to  129.3.  ]Many  patients  complain  of  insufficient  stool,  but 
careful  investigation  usually  shows  that  the  stools  are  numerous  and 
scanty  (according  to  Boas,  "fractional  stool"),  and  that  the  total  is 
up  to  the  average ;  or  there  may  be  colon  spasm,  which  gives  the  sense 
of  insufficient  emptying  of  the  lower  bowel.  Generally  the  frequency 
of  the  stools  corresponds  to  the  amount,  but  in  enteritis  there  are 
frequent  small  stools  with  tenesmus,  and  in  women  with  lax  abdominal 
walls  enormous  accumulations  may  be  found  in  the  rectum  and  sig- 
moid, while  they  still  declare  that  the  bowels  move  daily.  When 
stenosis  of  the  lower  bowel  is  present,  the  amount  of  feces  is  very 
much  diminished,  while  the  stools  are  very  numerous.  In  a  patient 
recently  under  the  author's  care,  with  stricture  of  the  descending 
colon  above  the  iliac  crest,  eight  to  ten  stools  occurred  daily.  One 
may  say,  on  the  whole,  that  a  movement  in  more  than  every  two  days, 
or  more  than  two  daily,  are  abnormal. 

CONSISTENCY  OF  STOOLS. 

The  consistency  of  stools  has  been  mentioned,  and  the  solid  stool, 
containing  scybala,  is  significant  of  long  delay  in  the  colon,  while  the 
semisolid  and  liquid  stool,  both  abnormal,  are  due  not  so  much  to  lack 
of  absorption  on  the  part  of  the  intestine  as  a  lively  watery  secretion 
by  it,  such  as  is  produced  by  saline  laxatives.  The  "lead  pencil"  or 
"ribbon"  stool  have  no  certain  connection  with  stenosis,  for  they  may 
occur  in  spastic  conditions  of  the  lower  bowel,  cramp  from  anal  fis- 
sure, etc.,  and  when  insufficient  food  is  taken,  while,  on  the  contrary, 
strictures  may  sometimes  be  accompanied  by  formed  stools  or,  more 
often,  by  diarrheal  stools.  One  can  rarely  rely  on  the  patient's  state- 
ment of  diarrhea.  For  instance,  in  inflammatory  processes  in  the 
rectum  or  sigmoid  there  may  be  several  movements  daily,  consisting 


170  DISEASES   OP   THE   DIGESTIVE   TRACT 

of  mucus,  blood,  and  serous  fluid,  only  once  or  twice  daily  mixed  with 
fecal  matter,  or  there  may  be  only  one  very  watery  stool  daily.  Both 
conditions  are  accounted  diarrhea  by  the  patient,  and  it  is  often  ex- 
asperating that  it  takes  so  much  questioning  to  learn  the  actual  num- 
ber and  consistence  of  the  movements  from  the  patient.  Perhaps  the 
best  way  is  to  ask  the  number  of  stools  daily  and  then  be  shown  the 
stool.  The  "nervous"  increased  peristalsis  of  the  intestine  occurs 
with  almost  no  disturbance  of  the  mucous  membrane,  while  ordinarily 
exaggerated  intestinal  motility  is  dependent  on  irritation  due  to  ab- 
normal contents — as,  for  instance,  the  meat  fragments  in  gastric 
achylia,  local  processes  (as  inflammation  of  its  mucous  membrane), 
or  ulcer,  or  blood  poison  (as  in  uremia  or  sepsis).  Watery,  bad-smell- 
ing stools  may  be  present  with  catarrh  of  the  large  or  small  intestine, 
but  in  the  latter  case  only  when  the  colon  is  involved,  since  it  is  the 
function  of  this  part  of  the  tract,  and  particularly  its  first  portion, 
to  solidify  the  feces  by  the  process  of  absorbing  the  water  contained 
in  it ;  in  fact,  this  decision  as  to  whether  the  large,  small,  or  both  por- 
tions of  the  tract  are  effected,  considered  fully  by  the  author  in  an 
article,^  is  one  often  of  great  difficulty.  In  general,  we  may  say  that 
when  no  large  amount  of  unabsorbed  food  remnants,  bilirubin,  nor 
partially  digested  (frog  spawn)  mucus  is  visible,  the  difficulty  is  con- 
fined to  the  colon.  Infrequently  hard  stools  with  scybala,  or  pasty 
stools  containing  the  latter,  indicate  that  the  difficulty  is  confined  to 
the  colon,  though  even  here  microscopic  examination  will  show  numer- 
ous evidences  of  involvement  of  the  small  intestine  in  the  presence 
of  abundant  food  remnants,  and  finely  divided  mucus  with  partially 
digested  epithelial  cells  and  cell  nuclei  embedded. 

COLOR  OF  FECES. 

The  color  of  the  feces  on  a  predominating  milk  diet  is  light-yellow, 
much  like  that  of  an  infant,  while  when  meat  is  in  excess  the  stool  is 
dark.  On  the  test  diet  light-yellow  predominates,  while,  if  spinach 
or  lettuce  is  taken  largely,  the  stool  has  a  distinctly  green  color,  not 
to  be  differentiated  from  bile-stained  feces  after  they  come  in  con- 
tact with  the  air.  All  of  these  confusing  characteristics  can  be  avoided 
by  the  test  diet  with  no  medication,  for  calomel  imparts  a  green  color, 
and  rhubarb  and  senna  a  yellowish -brown.  The  most  characteristic 
of  all  colors  is  the  gray  or  "clayey,"  which  is  found  in  obstruction  of 
the  common  duct  or  absence  of  pancreatic  juice  from  the  duodenum, 

^  Boston  Med.  and  Surg.  Jour.,  elxviii,  6. 


Fig.  30. — Microscopic  appearance  of  meat  libers  in  stool  well  stained  by  hydrobilirubin. 


Fig.    31. — Microscopic  appearance   of   meat    IiIjCvs   in   stool   stained   with    nile   lilue   sulphate. 
a,  meat  libers;  b,  plant  fragments.     (I.ohrisch.) 


EXAMINATION   OF   FECES  171 

either  from  blocking  of  Wirsung  's  duct  or  destructive  processes  in  the 
pancreas  itself,  as  well  as  those  of  the  mesenteric  glands.  As  these 
colorless  stools  usually  contain  a  large  excess  of  fat,  they  are  always 
salvelike  in  consistency.  All  colorless  stools,  however,  are  not  as- 
sociated with  absence  of  bile  pigment  (from  which  the  natural  color 
stercobilin  is  formed)  from  the  tract,  for  reduction  of  the  pigment  by 
bacteria  may  be  so  active  that  a  colorless  product  (leucobilin)  may 
result.  Such  a  stool,  however,  rapidly  darkens  on  exposure  to  light, 
or  the  alcoholic  extract,  when  a  few  drops  of  the  aldehyde  reagent  de- 
scribed on  page  168  are  added  to  it,  gives  a  bright  cherry-red  color. 
The  black  or  tarry  stool,  when  neither  bismuth  or  iron  has  been  taken, 
is  always  proof  of  bleeding  in  the  upper  intestinal  tract — that  is,  any- 
where from  the  duodenum  to  the  sigmoid ;  below  that  point  blood  main- 
tains its  characteristic  color,  though  when  peristalsis  is  much  exagger- 
ated blood  from  above  this  point  may  be  red.  Most  frequently,  how- 
ever, the  amount  of  blood  is  so  slight  (as  from  a  chronic  ulcer)  that 
it  gives  no  color  to  the  feces  and  can  be  detected  only  by  a  chemical 
test,  which  should  never  be  neglected  when  any  suspicion  of  ulcer  or 
cancer  exists. 

ODOR  OF  FECES. 

The  odor  of  the  feces  is  dependent  on  the  indol  and  skatol,  as  both 
are  the  products  of  the  putrefactive  action  of  bacteria  on  protein, 
which  is  inhibited  by  hydrochloric  acid.  The  author  was,  however, 
able  to  show  that  the  effect  of  the  acid  of  the  stomach  did  not  extend 
beyond  the  pylorus,  and  that  its  amount  bore  no  relation  to  the 
quantity  of  these  aromatic  products  in  the  feces.^  Some  errors  which 
prevail  about  the  odor  of  stools  should  be  corrected.  The  odor  of  the 
clay-colored  stool  is  not  unpleasant,  being  at  most  that  of  fatty  acids 
(rancid  butter)  ;  that  of  the  stool  in  fermentative  intestinal  dyspepsia 
is  sour,  and  very  often  the  contents  of  the  container  are  under  pres- 
sure and  nearly  blown  out  of  it  when  the  cover  is  removed,  which 
should  always  be  done  under  a  towel.  The  stool  on  the  test  diet  has 
almost  no  odor,  while  the  odor  when  there  is  a  disintegrating  cancer 
of  the  lower  bowel  is  most  penetrating,  highly  putrefactive,  and 
nauseating.  Boas  calls  it ' '  Aashaf  t, ' '  but  a  similar  odor  may  be  some- 
times found  where  there  is  a  large  meat  residue  in  the  stools  with  ac- 
tive putrefaction.  Excessive  mucus  in  the  stool  without  putrefac- 
tion may  give  a  glue-like  odor  to  feces. 

^  Boston  Med.  and  Surg.  Jour.,  Dec.  17,   1903. 


172  DISEASES  OP  THE  DICS:aTjyE   TRACT 

FOOD  FRAGMENTS. 

The  food  fragments,  when  macroscopic  examination  is  made  of 
feces,  where  the  patient  is  not  on  the  regulated  diet,  form  a  large 
residue,  consisting  of  connective  tissue  from  the  tough  meats  of  old 
animals  (often  called  "canners"),  bits  of  egg  shells,  fish  bones,  frag- 
ments of  intercellular  plant  tissue'  from  lettuce,  celery,  and  spinach, 
skins  and  seeds  of  berries,  and  of  pease  and  beans,  especially  when  old. 
The  well-known  breakfast  foods  are  noted  for  abundant  residue  in  the 
feces,  which  reminds  one  of  Du  Bois  Raymond's  retort  to  a  student 
who  mentioned  castor  oil  as  one  of  the  fatty  foods,  ''that  it  must  be  a 
negative  food."  This  material  can  usually  be  detected  with  the 
naked  eye,  but  with  the  test  diet,  apart  sometimes  from  large  masses 
of  connective  tissue  in  gastric  achylia,  practically  nothing  can  be 
identified  by  the  unaided  eye,  and  we  must  have  recourse  to  the  micro- 
scope. It  is  true  that  the  degree  of  mastication  affects  to  a  certain 
extent  the  macroscopic  residue,  but  ordinarily  any  considerable  amount 
of  gross  objects  in  the  stool,  if  the  diet  has  been  closely  adhered  to, 
is  pathological. 

NORMAL  STOOL. 

The  normal  stool  under  the  microscope  in  the  native  preparation  of 
the  slide.  Fig.  28,  shows  a  few  well-rounded  yellow  meat  fibers  (a), 
usually  without  striations;  white  (&)  and  yellow  (c)  calcium  soaps, 
the  latter  stained  with  hydrobilirubin ;  celluose  from  bread  and  cocoa 
(d,  g)  ;  and  a  few  empty  potato  cells  (e).  The  Lugol  and  nile  blue 
sulphate  solution  slides  show  nothing  characteristic,  except  that  in 
the  latter  meat  fibers  are  stained  light-blue  and  plant  fragments  green. 
When  any  doubt  exists  in  regard  to  the  character  of  the  lime  soaps 
and  they  assume  most  varied  shapes,  a  little  of  the  stool  should  be 
mixed  with  a  drop  of  acetic  acid  on  the  slide,  warmed,  cooled,  and  ex- 
amined.    The  lime  soaps  will  be  replaced  by  fat  globules. 

PATHOLOGIC  STOOL. 

The  pathologic  stool  often  shows  grossly  numerous  fragments  of  a 
yellowish-white  color,  which  may  be  so  numerous  as  to  present  the 
appearance  of  gossamer.  At  first  one  is  in  doubt  whether  he  is 
dealing  with  mucus  or  connective  tissue,  but  the  microscope  shows" 
the  former  to  be  studded  often  with  fragmentary  epithelial  cells  or 


Fig.    32. — Fat   clumps   in   mi.xed   feces  from   test   di 

(A.    Sciimidt.) 


<?t.      a,    fat   cliimi..s;   b.   mucus  flakes. 


Fig.   33.— Gross  appearance   of   fatty  stools  with   distiirlied   absorption.      (A.    Schmidt.) 


EXAMINATION   OF   FECES  173 

their  nuclei,  well  brought  out  by  neutral  red,  and  the  latter  by  well- 
stained  meat  fibers.  Furthermore,  a  drop  of  30  per  cent  acetic  acid 
may  be  added  to  such  a  shred  when  in  doubt,  which  will  bring  out 
distinctly  the  lines  extending  along  a  mass  of  mucus,  but  will  obliter- 
ate those  in  connective  tissue.  Certain  vegetables,  like  lettuce  and 
spinach,  when  the  individual  is  not  on  the  test  diet,  may  confuse  one 
from  their  resemblance  to  both  these  objects,  but  the  tracing  is  much 
less  delicate,  there  are  cross  lines,  and  the  whole  is  unaffected  by 
acetic  acid.  Reference  has  been  made  to  the  occurrence  of  these  con- 
nective tissue  remnants  and  their  significance,  and,  while  the  matter 
is  not  wholly  settled,  A.  Schmidt  still  insists  that  the  material  is  di- 
gested only  by  the  gastric  juice,  and  when  present  in  any  amount  in- 
dicates an  impaired  gastric  function,  usually  diminution  or  absence  of 
hydrochloric  acid.  This  is  true  in  real  achylia,  but  there  are  many 
conditions  other  than  these  where  connective  tissue  is  common,  pos- 
sibly due,  as  the  former  author  says,  to  the  meat  having  come  from 
old,  tough  animals,  M-ithout  proper  ripening.  Since  the  connective 
tissue  of  well-cooked  meat  can  be  entirely  dissolved  by  the  digestive 
juices,  particular  care  should  be  taken  that  the  chopped  meat  in  the 
test  diet  is  eaten  rare.  Salted  or  smoked  meat  is  much  more  difficult 
of  digestion,  and  hence  its  connective  tissue  is  much  oftener  found  in 
the  feces  and  has  much  less  significance. 

Meat  Fibers. — Fragments  made  up  of  meat  fibers  are  described  as  be- 
ing so  numerous  that  they  can  be  detected  by  the  naked  eye,  but  it  has 
never  been  the  author's  good  fortune  to  see  them  in  such  abundance, 
Under  the  microscope,  however,  they  are  readily  detected  from  their 
brilliant-yellow  or  reddish-brown  coloring,  dependent  on  the  amount  of 
hydrobilirubin  in  the  stool,  and  their  more  or  less  distince  striations. 
Their  pathologic  significance  is  dependent  on  their  number,  an  increase 
of  which  one  soon  learns  to  recognize  by  the  fact  that  they  are  heaped 
up  or  grouped  instead  of  being  isolated,  their  square  corners  and  main- 
tenance of  striations  instead  of  rounded  corners,  and  the  absence  of 
striae  when  digestion  is  vigorous.  The  nile  blue  sulphate  slide,  too, 
shows  these  muscle  fibers  stained  a  beautiful  light-blue,  much  like  a 
robin's  egg  (Fig.  31,  a). 

The  significance  of  a  large  number  of  these  muscle  fibers  is  that 
duodenal  digestion  is  impaired,  due  to  defective  secretion  of  pan- 
creatic juice.  Achylia  gastrica  alone  can  produce  abundant  connec- 
tive tissue,  but  not  muscle  fibers  in  the  stool  of  the  test  diet.  If  the 
pancreatic  digestion  alone  is  impaired,  we  have  muscle  fibers,  but  no 
connective  tissue ;  if  both  are  simultaneously  impaired,  because  hydro- 


174  DISEASES   OF   THE   DIGESTIVE   TRACT 

chloric  acid  stimulates  pancreatic  juice  secretion,  we  have  both  va- 
rieties of  meat  remnants  present.  The  disturbance  of  pancreatic 
digestion  does  not  necessarily  mean  impaired  secretion,  for  often  the 
increased  motility  of  the  small  intestines  carries  the  food  forward  be- 
fore there  is  sufficient  time  for  its  complete  digestion;  then,  again, 
insufficient  absorption  may  also  be  the  cause  of  the  appearance  of  fibers 
in  the  feces.  In  both  of  the  last  instances  trypsin  wdll  appear  in  the 
feces,  or,  after  the  oil  meal,  in  the  stomach,  but,  if  the  pancreatic  juice 
is  suppressed,  in  neither.  While  ordinarily,  w^hen  large  numbers  of 
fibers  are  found  in  the  feces,  they  contain  no  nuclei,  still,  when  their 
number  exceeds  a  certain  limit,  nuclei  may  be  found.  A'.  Schmidt 
has  attempted  to  make  this  occurrence  synchronous  with  the  absolute 
suppression  of  the  outer  secretion  of  the  pancreas,  but  many  investi- 
gators have  strongly  opposed  this  view,  and  it  evidently  has  not  been 
fully  proven. 

Fat. — Fat  is  usually  found  in  the  stool  of  the  test  diet  in  three  forms. 
First,  when  diarrhea  is  present,  we  have  small  yellowish-white,  soft 
masses,  which  consist  solely  of  fat.  In  diseases  of  the  pancreas  we 
often  see  stools  which,  when  passed,  consist  almost  entirely  of  fluid 
fat,  but  solidify,  later  on  cooling,  and  then  appear  exactly  like  butter 
which  has  been  melted  and  then  allowed  to  cool.  Much  more  common 
is  the  typical  fatty  stool  of  yellowish-white  (clayey)  color  and  pasty 
consistency,  which  is  generally  recognized.  In  this  will  be  seen  small 
fat  clumps,  but  it  is  made  up  chiefly  of  fatty  acid  and  soap  crystals 
thoroughly  mixed  with  other  fecal  matter. 

Microscopic  Examination. — The  microscopic  examination  of  the 
plain  slide  shows  vast  numbers  of  long  delicate  needles  and  shorter 
plumper  ones,  very  often  arranged  in  groups.  These  are  fatty  acid 
crystals  and  magnesium  and  calcium  soap  crystals,  which,  by  warm- 
ing with  a  drop  of  acetic  acid  and  allowing  to  cool,  may  be  changed 
to  oil  drops,  but  which  can  more  readily  be  distinguished  in  the  third 
slide  stained  with  nile  blue  sulphate  (Figs.  34  and  35).  Here  the  neu- 
tral fat  is  colored  red,  the  fatty  acids  a  deep-blue,  while  the  fats  which 
are  partially  split  into  acids  are  violet.  The  soap  crystals  undergo  no 
change  of  color,  but  the  pretzel-shaped  masses  become  colored  a  dark- 
gray  blue.  These  masses  of  fatty  acids  and  soap  frequently  assume 
some  size,  are  often  well  stained  with  hydrobilirubin,  or  even  bilirubin 
when  diarrhea  is  marked,  and  are  often  exaggerated  by  some  who  give 
patients  large  quantities  of  sweet  oil  and  then  pick  out  these  masses 
from  the  stool,  demonstrating  them  to  the  patients,  and  unfortunately 
sometimes  to   inexperienced  physicians,   as   gallstones.     It   has   been 


Fig.  34. — Microscopic  appearance  of  fat  in  stools  stained  witli  nile  blue  sulphate,     a,  neutral 

fat;  b,  calcium  soaps. 


Fig.   35.— Microscopic  appearance  of  partially  digested  fat,  stained  with  nile  blue  sulphate. 
a,   fatty   acids;    b,   partially   split   fat.      (tohrisch.) 


EXAMINATION   OF   FECES 


175 


the  author's  experience  to  see  these  shown  at  medical  meetings  as  a 
proof  of  the  wonderful  effect  of  olive  oil  in  the  solution  and  elimina- 
tion of  concrements  of  the  gallbladder.  The  butter  stool,  so-called, 
of  destructive  pancreatic  disease  is  found  under  the  microscope  to  be 
made  up  of  numerous  oil  drops  and  irregular  masses  of  a  grayish 
hue,  which  will  be  found  stained  red  in  the  third  slide.  By  gently 
warming  the  native  slide  without  acid,  all  of  these  masses — unless, 
as  sometimes  happens,  casein  is  present  with  fat  adherent  and  in  its 
meshes — will  be  found  to  have  resolved  themselves  into  groups  of 


Fig.  36. 


-Microscopic  appearance  of  unstained  fatty  stools,  fatty  acids  in  excess, 
globules;  b,  fatty  acids.      (A.  Schmidt.) 


fat  globules.  As  a  quantitative  estimation  of  the  several  amounts  of 
fatty  acids,  soaps,  and  neutral  fats  is  impracticable  in  a  clinic,  we  are 
compelled  to  form  a  judgment  of  the  relative  proportion  of  these  differ- 
ent forms,  much  as  a  practiced  eye  can  detect  a  leucocytosis  by  merely 
glancing  at  a  smear  of  blood  without  being  actually  able  to  state  the 
grade  or  extent.  So,  in  examining  a  specimen  of  feces,  if  well  mixed, 
we  may  say  at  once  the  fatty  acids  or  soaps  far  exceed  the  neutral  fats 
in  amount,  or  vice  versa.  This  excess  of  one  over  the  other  answers 
roughly  the   query  whether  pancreatic  secretion  is  impaired    (pre- 


176  DISEASES   OP   THE   DIGESTIVE   TRACT 

ponderance  of  neutral  fat),  or  absorption  is  diminished  by  exclusion 
of  bile  from  the  intestinal  tract,  or  tabes  mesenterica  (greater  pro- 
portion of  fatty  acids  and  soaps).  Unfortunately,  as  has  been  stated, 
the  subsequent  splitting  of  fat  by  bacteria  in  the  lower  bowel  has 
robbed  neutral  fat  predominance  of  its  significance  as  a  proof  of  ex- 
clusion of  pancreatic  juice,  and  Zoja  has  suggested  that  a  lessened 
amount  of  soaps  has  the  same  clinical  value,  because  the  loss  of  alkali 
from  the  lessened  secretion  of  the  pancreas  interferes  very  much  w^ith 
soap  production.  In  cases  of  pancreatic  disease  the  loss  of  fat,  which 
appears  in  the  stool,  may  be  from  20  per  cent  to  80  per  cent,  de- 
pendent on  the  extent  of  the  still  remaining  normal  secreting  struc- 
ture, and  only  secondarily  on  the  obstruction  of  its  flow  to  the  in- 
testine. If  pancreatic  disease  is  combined  with  obstruction  to  the 
bile,  the  loss  of  fat  is  not  greater  than  is  the  absence  of  bile  alone. 
Intestinal  dyspepsia  and  catarrh  do  not  interfere  to  a  very  great  ex- 
tent with  the  absorption  of  fat,  and  the  general  opinion  that  with 
every  intestinal  indigestion  or  catarrh  the  absorption  of  the  fat  is  the 
first  to  suffer  is  not  substantiated.  Much  oftener,  in  the  writer's  ex- 
perience, the  protein,  particularly  in  the  form  of  meat,  is  first  met 
in  large  quantities  in  the  stool. 

Carbohydrates. — Carbohydrates  are  never  found  in  a  normal  stool 
from  the  test  diet,  but  under  pathologic  conditions  they  appear  in 
notable  quantities.  They  arise  almost  always  from  the  potato  puree 
and  only  in  very  severe  disturbances  from  the  bread.  Macroseopi- 
cally,  it  is  very  rare  that  they  are  seen,  and  then  usually  because  the 
puree  was  not  sufficiently  macerated,  so  that  lumps  were  left  in  it. 
These  appear  in  the  stool  as  glassy,  transparent,  sago-like  masses, 
formerly  supposed  to  be  fragments  of  mucus.  In  the  writer's  ex- 
perience only  by  means  of  the  microscope  can  the  differentiation  be- 
tween fragments  of  potato  starch  and  mucus  be  made,  by  which,  par- 
ticularly in  the  iodine  slide,  the  large  potato  cells  are  found  to  con- 
tain a  few  blue  starch  granules.  Much  more  common,  when  examined 
microscopically,  are  the  isolated  blue  starch  granules,  which  are  dis- 
tended, thereby  losing  their  oval  form  and  concentric  lines.  Another 
common  form  is  the  amethyst-colored  remnants  found  attached  to 
the  cellulose.  All  of  these  can  be  distinguished  only  on  the  slide  to 
which  Lugol's  solution  has  been  added,  because,  due  to  partial  di- 
gestion, they  have  no  distinctive  form.  Chemical  tests  for  carbohy- 
drate in  stool  are  awkward  and  of  little  value,  but  much  can  be  learned 
as  to  their  presence  by  the  active  fermentation  noted  in  the  jar  when 
opened  and  the  acid  reaction,  both  of  which  can  be  further  verified 


jgg^SSN^ 


Fig.    37. — Fermentative   stools   containing   potato   cells    and   Clostridia,    stained    with   Liigol's 

solution.     CA.  Schmidt.) 


EXAMINATION   OF    FECES  177 

by  thinning  somewhat  the  solution  of  the  feces  employed  for  micro- 
scopic examination  and  pouring  it  into  an  ordinary  fermentation  tube, 
which,  if  allowed  to  remain  in  a  warm  place  (not  necessarily  a  thermo- 
stat), for  twenty- four  hours,  will  show  an  excessive  amount  of  gas 
in  the  longer  arm  of  the  tube  and  the  reaction  will  be  strongly  acid  if 
carbohydrates  are  abundant  in  the  stool.  On  the  contrary,  it  should 
be  said  that,  if  under  the  same  conditions  the  reaction  is  alkaline,  it  in- 
dicates an  excessive  protein  residue  in  the  feces,  either  from  food 
remnants  or  from  pathologic  excretion  of  mucus,  pus,  or  blood.  As 
sugar  is  never  found  in  the  stool,  and  cellulose  ferments  very  slowly 
apart  from  the  intestine,  the  fermentation  of  the  feces  may  be  taken 
without  question  as  a  proof  of  a  large  starch  residue.  The  fermenta- 
tion tube  has  always  been  used  by  the  writer,  as  well  as  the  more 
complicated  instrument  of  Schmidt,  and  is  much  more  cleanly  to  work 
with.  In  persons  with  a  normal  intestinal  digestion  on  the  test  diet 
the  starch  disappears  absolutely,  but  on  a  self-chosen  diet  starch 
granules  often  appear  in  the  celluose  remnants.  The  most  frequent 
cause  of  starch  in  the  stool  on  the  test  diet  is  fermentative  intestinal 
dyspepsia,  which  Schmidt  has  found  to  be  due  to  the  impaired  digestion 
of  cellulose.  This  form  of  dyspepsia  or  indigestion  passes  over  into  a 
form  of  intestinal  catarrh,  and  then,  of  course,  the  loss  of  carbohydrate 
is  much  increased.  Duodenal  catarrh  also  may  lead  to  marked  loss  of 
starch  in  the  stool,  but  colon  catarrh  alone  is  always  accompanied  by  a 
most  excellent  utilization  of  this  form  of  food.  Absence  of  fecal 
starch  remnants  will  also  be  found  with  pancreatic  disease  and  obstruc- 
tion of  the  bile,  while  even  with  severe  tubercular  disease  of  the  in- 
testine or  mesenteric  glands,  where  the  fat  absorption  suffers  notably, 
it  is  astonishing  to  mark  the  almost  complete  absence  of  starch  from 
the  stool.  AVhenever  carbohydrate  remnants  are  found  in  the  feces, 
it  k  customary  to  see  large  empty  potato  cells,  while  in  the  stool  of  the 
normal  individual  they  are  rare,  and  in  the  constipated  are  never 
found.  Schmidt,  from  this  circumstance,  infers  that  diarrheas  of  cer- 
tain kinds  are  dependent  on  a  faulty  digestion  of  cellulose,  while  con- 
stipation rests  on  a  too  vigorous  digestion  of  the  same  material. 

Decomposition  Products  of  Food  Material. — Decomposition  prod- 
ucts of  food  material  have  played  a  very  prominent  part  in  medicine 
since  the  habit  of  ascribing  all  obscure  symptoms  of  a  nervous  nature 
to  autointoxication.  Of  these,  indol  and  skatol  are  the  most  impor- 
tant, but  the  detection  of  their  increase  is  so  complicated  and  beset 
with  so  many  difficulties  that,  as  a  clinical  method,  it  can  never  pre- 
vail, for,  since  these  two  substances  are  absorbed  to  a  certain  extent 


178  DISEASES   OP   THE   DIGESTIVE   TRACT 

and  appear  in  the  urine,  rendered  innocuous  by  union  with  sulphuric 
acid,  we  must  quantitate  both  urine  and  feces  to  obtain  the  total 
amount.  Then,  again,  it  has  been  proven  that  decomposition  in  the 
intestine  is  not  the  sole  source  at  least  of  indol,  for  in  starvation  and 
malnutrition  it  comes  from  active  retrograde  metamorphosis  of  the 
protein  material  of  the  body.  Up  to  a  certain  extent,  too,  the  body 
always  possesses  an  antidote  to  this  poison  in  both  sulphuric  and  glycu- 
ronic  acid,  as  shown  by  the  author.^  In  only  one  condition  has  the 
author  found  an  increased  urine  indican  test  of  any  value  in  diagnosis, 
and  that  is  to  aid  in  distinguishing  an  appendical  tumor  from  an 
inflamed  gallbladder.  The  former  usually  shows  a  strong  indican 
reaction  in  the  urine,  and  the  latter  a  trace  of  bile.  Another  long-re- 
spected view  that  flatus  in  the  intestines  was  due  to  increased  fermenta- 
tion must  be  given  up,  for  we  find  that,  where  examination  shows  the 
most  lively  fermentative  processes,  as  in  some  forms  of  intestinal  dys- 
pepsia, there  is  no  increase  of  gas.  Much  oftener  gas  is  due  to  faulty 
absorption,  particularly  where  stasis  from  a  leaking  heart  is  begin- 
ning, or,  more  recently,  it  has  been  shown  that  carbon  dioxide  may  be 
eliminated  from  overcharged  blood  into  the  intestine,  a  compensatory 
means  of  excretion  from  the  lungs. 

Digestive  Fluids. — The  digestive  fluids  leave  very  few  remnants, 
with  the  exception  of  the  stercobilin  or  hydrobilirubin,  the  means  for 
whose  detection  has  been  mentioned  on  page  168.  By  the  intensity  of 
the  red  color  we  are  able  to  draw  some  conclusion  as  to  the  amount  of 
this  pigment  in  the  feces.  Its  antecedents,  bilirubin  (yellowish- 
brown),  or  an  oxidized  product  of  the  same  produced  by  calomel  and 
sometimes  by  an  oxidase  of  colon  mucus,  biliverdin  (green),  rarely 
appear  in  feces,  and  then  only  when  peristalsis  is  very  much  hastened. 
If  their  presence  is  associated  with  catarrh  of  the  small  intestine,  they 
are  always  accompanied  by  an  abundance  of  food  remnants — starch, 
meat  fibers,  etc.  The  alcoholic  extract  of  the  feces  turns  green  when 
these  pigments  are  present  and  the  aldehyde  reagent  is  added.  As  to 
ferments,  there  is  not  the  slightest  doubt  that  they  appear  in  the  stools 
increased  when  peristalsis  is  exaggerated,  but,  apart  from  trypsin, 
animal  diastase  (amylopsin),  and  erepsin,  no  practical  use  has  ever 
been  made  of  their  detection  for  clinical  purposes.  The  author's  per- 
sonal experience  has  been  limited  to  trypsin,  which,  on  account  of  the 
fact  that  the  innumerable  bacteria  found  in  the  intestine,  and  particu- 
larly the  colon  bacillus,  have  the  power  of  splitting  protein  as  the 
trypsin  does,  employing  the  feces  for  the  detection  of  this  ferment,  by 

1  Salkowski's  Festschrift,  53. 


EXAMINATION   OF   FECES  179 

which  we  attempt  to  learn  whether  the  pancreas  is  functionally  active, 
is  very  unsatisfactory.  It  is  much  better  to  employ  the  gastric  con- 
tents after  an  oil  meal,  which  should  be  given  in  the  manner  here  de- 
scribed, as  employed  by  the  author  as  a  routine  examination  in  the 
clinic  when  we  wish  to  investigate  the  pancreatic  functions.  Wash 
out  the  fasting  stomach  and  then  give  the  patient  a  glass  of  good  sweet 
oil,  which  he  usually  drinks  readily,  or  it  may  be  poured  down  the 
tube  after  washing  the  stomach;  then  the  patient  takes  a  teaspoonful 
of  magnesium  oxide,  suspended  in  water  to  neutralize  the  hydrochloric 
acid,  which  with  pepsin  destroys  the  trypsin ;  in  forty-five  minutes 
the  oil  and  duodenal  contents  are  removed  with  the  tube,  the  oil  rises 
to  the  surface,  and  the  digestive  fluid  can  be  removed  by  a  pipette ;  the 
blue  litmus  paper  should  not  be  changed  by  it,  or  further  use  is  im- 
practicable ;  if  neutral  or  alkaline,  a  small  piece  of  boiled  egg  may  be 
placed  in  some  of  it  in  a  warm  place,  or  the  Gross  test  (page  154) 
may  be  employed  with  a  solution  of  0.5  gram  casein  in  a  liter  of  0.1 
per  cent  sodium  bicarbonate  solution  and  the  use  of  1  per  cent  acetic 
acid  for  a  precipitant  instead  of  sodium  acetate  solution.  If  no 
trypsin  is  present,  all  the  tubes  have  a  precipitate.  In  perfectly 
normal  pancreatic  digestion,  trypsin  has  never  been  missed  by  the 
author  in  the  contents  withdrawn  from  the  stomach  after  the  oil  meal. 

Inorganic  Detritus. — The  inorganic  detritus  in  stools — triple  phos- 
phate, calcium  oxalate,  and  cholesterin  crystals — have  never  offered 
the  author  the  slightest  aid  in  a  clinical  way.  Charcot-Leyden  crys- 
tals have  been  seen  without  the  presence  of  parasites,  whose  associa- 
tion is  commonly  believed,  and  the  hematoidin  crystals,  where  the  sur- 
geon (Mumford)  found  a  collapsed  ribbon-like  colon  and  made  an 
anastomosis  between  the  cecum  and  the  sigmoid.  Bismuth  crystals 
and  small  fragments  of  charcoal,  both  intensely  black,  one  is  sure  to 
come  on  and  should  be  familiar  with  their  appearance.  Their  elimina- 
tion from  the  intestine  is  very  slow,  and  they  may  be  found  days  after 
their  medicinal  use  has  ceased.  With  real  gallstones  in  the  feces  it 
has  never  been  the  author 's  good  fortune  to  meet.  ' '  Intestinal  gravel, ' ' 
as  it  is  sometimes  called,  is  not  so  rare,  and,  while  the  most  of  it 
springs  from  seeds  and  calcareous  masses  from  the  union  of  lime  with 
fatty  acids,  some  in  the  author's  experience  have  shown  evidence  of 
former  facetted  surfaces,  not  unlike  what  has  been  seen  by  surgeons 
in  the  gallbladder,  when,  in  spite  of  symptoms,  no  large  stone  was 
found.  Whatever  the  reason  for  their  disintegration  may  have  been, 
they  are  clearly  fragments  of  broken-down  gallstones,  and  a  small 
fragment  picked  up  with  the  pipette  from  the  debris  left,  after  pour- 


180  DISEASES   OF   THE  DIGESTIVE   TRACT 

ing  off  the  liquid  portion  of  the  feces,  ground  up  with  the  end  of  a 
glass  rod,  extracted  with  a  few  drops  of  hot  alcohol  on  a  slide  and  the 
liquid  transferred  to  another,  will,  on  evaporation,  show  the  charac- 
teristic crystals  of  cholesterin. 

PATHOLOGIC  PRODUCTS  OF  THE  INTESTINAL  MUCOUS 

MEMBRANE. 

The  most  common  of  these  products  and  that  having  the  greatest 
diagnostic  significance,  is  the  mucus,  which  may  be  found  in  long 
shreds,  or  so  finely  divided  that  it  looks  like  a  scum  floating' on  the 
surface  of  the  liquefied  feces.  Ordinarily  it  is  useless  to  examine  with 
a  microscope  if  no  fragments  can  be  clearly  distinguished  by  the  naked 
eye,  but  when  it  is  finely  divided  by  digestion,  coming  apparently  from 
the  small  intestine,  a  spatula  slipped  under  this  scum  will  often  re- 
move enough  to  transfer  to  a  slide,  from  which  often  a  very  good  pic- 
ture of  the  condition  of  the  mucous  membrane  of  the  intestine  can  be 
obtained.  The  mucus  usually  appears  as  glassy,  transparent,  colorless 
shreds  and  masses,  which  either  cling  to  the  outside  of  a  formed  stool 
or  are  intimately  mixed,  and  first  become  visible  when  the  feces  are 
macerated.  Then,  again,  we  have  the  ribbon  and  string-like  forms, 
which  may  be  bro\^Ti  or  opaque  from  adherent  fat,  and  epithelial  cells, 
leather-like  and  in  fragments,  so  long  that  patients  often  wash  them 
out  and  bring  them  to  the  physician  as  fragments  of  tapeworm. 

In  general  it  may  be  said  that  the  appearance  of  mucus  in  the  stool 
indicates  an  inflammatory  condition  of  some  portion  of  the  intestinal 
tract,  though  in  itself  it  gives  no  hint  as  to  the  site  or  extent.  The  site 
of  the  catarrhal  condition  may,  however,  often  be  determined  by  at- 
tendant circumstances,  all  mucus  that  is  visible  to  the  naked  eye  comes 
from  the  colon,  and  all  band-  and  tube-like  forms  and  clumps  clinging 
to  the  sides  of  the  stool  come  from  the  sigmoid  and  rectum.  When  the 
mucus  is  intimately  mixed  with  the  feces,  we  may  say  that  the  higher 
portions  of  the  tract  are  affected,  and  the  more  thorough  the  mixture 
the  higher  the  section.  The  mucus  from  the  small  intestine  is 
much  less  liable  to  be  found  in  the  feces,  first,  because  that  portion 
secretes  mucus  less  readily  than  the  colon,  and,  second,  because 
the  mucus  is  more  likely  to  be  digested.  Hence  the  inference  that 
mucus  comes  from  the  small  intestine  can  be  maintained  only  when 
the  fragments  are  very  minute,  associated  with  food  remnants,  and,  if 
stained  with  unchanged  bilirubin  and  partially  digested  epithelial  cells 
and  their  nuclei  are  present,  the  presumption  is  still  greater.     ]\Iucus 


EXAMINATION   OF   FECES 


181 


from  this  portion  of  the  intestine  is  usually  poor  in  cells,  but  rich  in 
bacteria,  while  in  fact,  if  the  inflammation  is  in  the  duodenum,  no 
mucus  at  all  may  be  present  in  the  feces.  We  can  never  judge  of  the 
intensity  of  the  inflammation  by  the  amount  of  mucus.  In  mucous 
colitis,  where  the  amount  of  mucus  is  very  large  and  its  discharge  with- 
out fecal  matter  is  often  accompanied  by  pain,  the  rectoromanoscope 
has  showTi  us  little  or  no  inflammation  of  the  mucous  membrane,  and 
apparently  the  stimulation  is  at  least  partially  controlled  by  nervous 


Fig.  38. — Microscopic  appearance  of  mucus  from  small  intestine,  containing  fatty  acids  and 
partially  digested  epithelial  cells.      (Schmidt  and  Strassburger.) 

influences,  and  this  is  further  proved  by  the  transparency  of  the  mucus 
and  its  poverty  in  epithelial  cells.  The  opacity  of  the  mucus,  how- 
ever, does  not  always  bear  a  constant  relation  to  the  number  of  cells, 
because  it  may  be  produced  by  the  imbibition  of  fat.  When  we  find, 
by  microscopic  examination,  numerous  epithelial  cells,  especially  with 
leucocytes,  the  inflammatory  character  of  the  lesion  is  assured;  still, 
the  superficial  layer  of  the  mucous  membrane  may  lose  enormous  num- 
bers of  its  cells  without  its  having  undergone  serious  pathologic 
changes.     In  catarrhs  of  the  colon  the  epithelial  cells  and  also  the 


182 


DISEASES  OF   THE   DIGESTIVE   TRACT 


leucocytes  are  often  found  shriveled,  which,  according  to  A.  Schmidt, 
is  due  to  a  rigidity  and  contraction  produced  by  the  absorption  of 
fatty  soaps,  which  also  cause  a  loss  of  the  characteristic  cell  forma- 
tion, but  retention  of  the  nuclei  that  are  still  susceptible  of  staining. 
In  those  minute  fragments  of  mucus  which  are  driven  from  the  small 
intestine  these  distorted  epithelial  cells  are  rarely  found.  The  cells 
are  almost  invariably  of  the  cylinder  variety,  while  the  pavement  cells, 


Fig.  39. — Microscopic  appearance  of  colon  mucus  with  "shriveled"  cells.      (Schmidt  and 

Strassburger.) 

if  present,  are  from  the  anus,  or  possibly  nucleus  free,  hardened  speci- 
mens from  the  mouth.  The  leucocytes  are  polymorphonuclear  and 
contain  all  sorts  of  granulations.  By  the  formation  of  vacuoles  their 
size  may  be  increased  two  to  threefold,  and  they  then  resemble  very 
closely  the  motionless  amebse. 

Pus. — Pus  appears  in  the  feces  as  very  numerous  leucocytes  at- 
tached to  a  fragment  of  mucus,  which  forms  a  slender  means  of  union 
to  the  various  corpuscles.    Free  or  unattached  pus  is  very  seldom 


EXAMINATION   OP   FECES 


183 


seen,  and,  because  of  its  admixture  with  the  stool,  is  very  difficult  to 
distinguish  either  with  the  naked  eye  or  with  the  microscope.  In  hun- 
dreds of  examination  of  stools,  only  twice  has  pus  been  so  abundant 
that  one  could  say  at  a  glance  that  it  was  present — one  a  suppurating 
dermoid  cyst,  as  determined  at  autopsy,  which  had  broken  through 


_--c 


Fig.  40. — Microscopic  appearance  of  pus  flakes  from  feces  in  chronic  diarrhea,     a,  leucocytes; 
h,  epithelium;  c,  fatty  acid  needles;  e,  Charcot-Leyden  crystals. 


into  the  lower  intestine,  and  the  other  an  abscess  associated  with  malig- 
nant disease  of  the  sigmoid  and  stricture,  where  discharges  of  blood, 
pus,  and  mucus  occurred  without  fecal  matter.  Hence,  as  A.  Schmidt 
says,  when  a  large  amount  of  free  pus  is  discovered  in  the  stool,  one 
must  always  think  of  the  rupture  of  a  paraintestinal  abscess  in  the 
vicinity  of  the  lower  colon,  for,  if  an  appendical  abscess  ruptures 


184  DISEASES   OF    THE   DIGESTIVE   TRACT 

into  the  intestine,  or  there  is  an  ulcer  in  the  small  intestine  (typhoid  or 
tuberculosis),  the  pus  is  wholly  disintegrated  before  it  reaches  the 
outlet  of  the  tract.  On  the  contrary,  mucous  shreds  studded  with  pus 
can  spring  only  from  the  intestine,  and  such  are  found  with  dysentery, 
ulcer,  active  colitis,  neoplasm,  and  syphilis.  In  the  miscroscopic  pic- 
ture the  pus  corpuscles  are  often  found  in  a  state  of  fatty  degenera- 
tion, just  as  they  are  in  chronic  pyelitis. 

Tissue  Fragments. — Tissue  fragments  in  the  stool  are  undoubtedly 
found  from  ulcerative  colitis,  invagination,  polypus,  and  fragments  of 
iileerated  neoplasms,  but  the  liability  of  confusion  with  detached 
mucus  and  food  remnants  is  so  great  that  only  imbedding,  cuttiilg,  and 
careful  histological  examination  under  the  microscope  will  enable  one 
to  make  a  positive  statement. 

Blood  in  the  Feces. — Blood  in  the  feces  may  present  the  normal 
bright-red  color  when  alone  or  mixed  with  mucus  and  pus.  It  comes 
from  polypi  in  the  sigmoid  or  rectum,  from  hemorrhoids,  or  fissures  of 
the  anus.  When,  however,  it  remains  a  long  time  in  the  intestinal 
canal,  whether  it  comes  from  the  sigmoid  or  higher  up  in  the  canal, 
it  gives  a  brownish  hue  to  the  stool  and,  if  abundant,  black,  as  previ- 
ously described  (page  171).  Therefore,  in  spite  of  former  views  on 
the  subject,  apart  from  hemorrhage  at  the  anus,  the  degree  of  decom- 
position (change  from  hemoglobin,  red,  to  hematin,  brown)  of  the 
blood  gives  us  but  little  information  as  to  the  site  of  the  bleeding. 
Attendant  circumstances,  however,  often  shed  much  light  on  the  cause 
of  the  hemorrhage.  If,  for  instance,  the  blood  is  mixed  with  pus,  we 
may  assure  ourselves  that  it  comes  from  an  ulceration  in  the  intestinal 
tract.  When  the  blood  is  mixed  with  mucus,  it  denotes  severe  catarrhs, 
usually  of  the  colon,  polypus,  or  invagination.  Low-lying  malignant 
tumors  also  produce  this  combination,  and,  in  addition,  venous  stasis 
may  cause  bleeding  from  the  intestinal  canal.  AVhen  the  blood  is  red 
(hemoglobin),  the  corpuscles  can  usually  be  distinguished  by  the 
microscope,  but  when  they  are  brown  (hematin)  they  cannot,  and  we 
are  obliged  to  have  recourse  to  a  chemical  test.  When  the  hemorrhage 
is  minute  ("occult"),  it  imparts  no  characteristic  color  to  the  feces, 
and,  still,  the  latter  promptly  gives  the  reaction  for  "occult,"  or,  as 
R.  Schmidt  chooses  to  call  it,  "chemical"  blood.  Before  the  positive 
outcome  of  the  test  can  be  made  absolute,  the  patient  should  have  had 
a  laxative  (castor  oil)  and  then  have  refrained  three  days  from  meat, 
fish,  soup,  beef  tea,  or  anything  which  may  by  any  means  have  been 
brought  in  contact  with  blood. 

The  test  (based  on  Weber's  discovery)   is  performed  most  readily 


EXAMINATION   OF   FECES  185 

by  pouring  2  c.c.  of  glacial  acetic  acid  into  a  wide-mouthed  test  tube, 
and  with  a  glass  rod  removing  a  piece  of  feces,  if  solid,  as  large  as  a 
hazelnut  from  the  jar,  and  mixing  it  thoroughly  with  the  acid;  then 
the  solution  should  be  cooked  to  destroy  any  leucocyte  or  mucous 
oxidase,  taking  care  that  it  does  not  spurt  and  burn  the  operator,  for  it 
boils  at  a  very  low  temperature;  after  cooling,  an  equal  amount  of 
ether  or  alcohol  is  added,  and  the  whole  shaken  or  stirred  until  a  thor- 
ough mixing  is  produced.  Then  three  test  tubes  are  filled  with  2  c.c. 
of  alcohol  each ;  to  the  first  a  granule  of  solid  gum  guaiac  (not  the 
powder,  which  is  often  bluish-green  in  color)  is  added,  which  is  thor- 
oughly dissolved  with  the  aid  of  a  glass  rod,  and  a  few  drops  of  the 
solution  or  tincture  poured  into  test  tube  No.  2,  from  which  also  a 
few  drops  are  poured  into  No.  3,  so  that  we  have  guaiac  in  three  dilu- 
tions ;  then  to  each  an  equal  amount  of  good,  fresh  hydrogen  peroxide 
is  added  and  thoroughly  shaken.  Now,  to  each  of  these  tubes  in  turn, 
beginning  with  the  strongest  tincture,  a  few  drops  of  the  alcoholic  or 
ethereal  solution  of  acid  hematin,  into  which  the  digested  blood  is  con- 
verted by  glacial  acetic  acid  (if  blood  is  present),  are  added;  the  alco- 
holic extract  may  be  filtered,  and,  if  the  ethereal  does  not  separate 
readily,  a  few  drops  of  alcohol  may  be  added.  When  blood  is  present 
in  the  stool,  each  drop  of  the  glacial  acetic-alcoholic  extract,  as  soon  as 
it  strikes  the  mixture  in  one  or  all  of  the  tubes,  will  turn  greenish-blue 
to  distinct  blue.  The  intensity  of  the  reaction  will  vary  in  the  three 
tubes  in  correspondence  with  the  amount  of  blood.  Schroeder  has 
demonstrated  that  large  amounts  of  blood  demand  large  quantities  of 
guaiac,  and,  furthermore,  that  a  minute  quantity  of  blood  may  utterly 
fail  to  give  the  reaction  when  added  to  a  concentrated  solution  of  guaiac. 
Much  in  the  same  way  benzidine,  aloin,  and  paraphenylendiamine 
are  employed,  but  they  possess  no  advantage  over  guaiac  for  clinical 
purposes  where  undue  fineness  is  not  demanded,  and  a  reagent  like 
benzidine,  which  would  show  the  slightest  hemorrhage  from  the  gums 
or  pharynx  if  swallowed,  is  a  hindrance  rather  than  an  aid  when  one 
wishes  most  particularly  to  learn  whether  ulcer  which,  if  it  bleeds  at 
all,  produces  an  appreciable  amount  of  blood,  is  present.  When  all 
these  precautions  are  carried  out — determination  of  absence  of  sources 
of  bleeding  in  the  gums,  nose,  and  pharynx,  a  thorough  clearing  out 
of  the  intestinal  tract,  followed  by  three  days'  meat  free  diet,  and 
freedom  of  the  anus  from  hemorrhage  (fissure  or  hemorrhoids) — a 
positive  test  for  chemical  blood  can  be  utilized  as  perhaps  the  most 
diagnostic  point  in  favor  of  interruption  of  continuity  of  the  mucous 
membrane  of  the  tract,  as  ulcer,  cancer,  or  rupture  of  small  varicosities. 


186  DISEASES   OF   THE   DIGESTIVE   TRACT 

Bacteria. — The  bacteria  in  feces  offer  but  little  aid  to  diagnosis  in 
the  unstained  specimen,  for  they  all  "look  alike"  to  the  observer. 
When,  however,  on  an  iodine  slide  (as  we  will  call  it)  the  particle  of 
feces  is  well  rubbed  with  Lugol's  solution,  by  the  differential  staining 
produced  much  can  be  learned  in  regard  to  the  objects  affected.  The 
microbes  which  stain  blue  with  iodine  consist,  first,  of  the  rod-like 
bodies — oval,  lemon-like,  or  spindle-shaped  structures — which  might 
resemble  starch  granules  except  for  the  smaller  size  of  the  former,  or 
yeast  spores  except  that  the  latter  are  always  stained  yellowish-brown, 
thin  leptothrix-like  threads,  and  cocci.  The  thick  rods  and  spindle- 
shaped  forms  often  have  one  pole  unstained  or  with  cross  lines,  so  that 
they  appear  as  if  containing  spores.  They  have  received  various 
names — among  others,  Clostridium  butyricum — but  all  are  agreed  that 
they  have  the  power,  apart  from  oxygen  (anaerobic),  to  split  carbo- 
hydrates to  butyric  acid ;  apparently,  too,  the  yeast-like  bodies  belong 
to  this  group.  The  leptothrix-like  threads  and  the  cocci,  which  are 
sometimes  more  violet  after  iodine,  have  not  been  identified.  The 
failure  of  the  Boas-Oppler  bacilli  to  stain  as  contrasted  with  the  lepto- 
thrix,  which  closely  resembles  them,  should  be  carefully  noted.  The 
granulose-containing  organisms — i.e.,  those  that  stain  blue — are  never 
found  in  a  normal  stool  on  test  diet,  so  that  their  presence  in  any 
number  always  indicates  a  faulty  carbohydrate  utilization,  which  is 
verified  by  the  numerous  starch  granules  under  the  microscope  and 
the  results  of  the  fermentation  of  the  stool. 

Protozoa  of  the  Feces. — The  only  protozoa  of  the  feces  having  any 
clinical  significance  are  the  amebae  coli — one,  the  entameba  coli,  which 
is  harmless,  and  the  other,  entameba  histolytica,  the  cause  of  tropical 
dysentery,  which  causes  ulcerations  of  the  lower  colon  and  abscesses 
of  the  liver.  The  latter  was  fairly  common  in  our  invalided  soldiers 
from  the  Philippines  soon  after  the  Spanish-American  war,  before 
the  Army  Medical  Department  had  a  chance  to  clean  up  in  those  pos- 
sessions. The  entameba  coli  may  be  found  in  healthy  individuals,  and 
yet  are  found  often  in  patients  who  suffer  from  colon  catarrh ;  whether 
the  cause  of  it  or  a  result  of  favorable  conditions  for  growth  has  never 
been  determined.  They,  of  course,  soon  lose  their  motility  when  the 
stool  cools  and  are  found  embedded  in  the  mucus.  When  cool,  they 
not  only  lose  motion,  but  become  encysted  and  invisible,  so  that  the 
microscope  should  also  be  warmed  before  the  slide  is  examined.  In  the 
entameba  coli  the  nucleus  appears  very  distinct. 

Intestinal  Parasites. — Intestinal  parasites  are  commonly  found 
among  the  lower  classes  of  people,  especially  in  the  free  clinics,  though 


Fig.  41. — Microscopic  appearance  of  various  abnormal  fecal  bacteria,  a,  Clostridia  con- 
taining graniilose;  b,  yeast  spores;  c,  starch  granules;  d,  sarcin.i;;  e,  leptolhrix-like  threads; 
/,  bacilli  containing  granulose;  g^  cocci  containing  granulosa;  h,  Boas-Oppler  lactic  acid 
bacilli,  stained  with   Uugol's  solution.      (A.   Schmidt.) 


EXAMINATION  OF  FECES 


187 


those  in  better  circumstances  may  also  possess  them,  particularly  when 
rare  chopped  meat  was  included  in  the  diet  of  undeveloped  children. 
Suspicion  should  be  aroused  as  to  their  presence  by  numerous  eosino- 
philes  in  the  blood  or  Charcot-Leyden  crystals  in  the  stool.  The  con- 
clusive proof,  however,  is  in  finding  the  eggs  or  fragments  of  the 
worms,  which  must  be  differentiated  from  masses  of  mucus  or  food 
fragments,  an  undertaking  not  difficult  with  the  low  power  of  a  micro- 


Fig.  42. — Tenia  saginata,  showing  egg  of  same  enlarged  four  hundred  times. 

scope.  Only  the  more  common  forms  will  be  mentioned  here,  as  a  com- 
plete list,  with  description,  would  fill  a  volume.  The  group  one  most 
frequently  meets  is  the  tapeworms,  whose  possessor  is  said,  jointly 
with  an  editor,  to  be  able  to  use  the  editorial  ' '  we. ' '  Each  individual 
member  of  the  group  consists  of  a  small  head  with  a  sucking  apparatus, 
a  very  short  neck,  and  a  long  chain  of  segments,  or  proglottids,  which 
increase  by  forming  new  ones  from  the  old;  the  oldest  segments  are 


188 


DISEASES  OF   THE   DIGESTIVE   TRACT 


those  farthest  from  the  head  and  are  suitable  for  reproduction,  pro- 
ducing vast  numbers  of  eggs.  From  time  to  time  the  riper  segments 
are  detached  and  are  found  in  the  feces.  Most  of  these  parasites 
spring  from  embryos  in  the  meat  of  the  animal  in  whose  stomach  the 
eggs  from  the  feces  of  the  original  host  have  developed.     The  life  his- 


Fig.  43. — Segment  of  Tenia  saginata,  enlarged  twelve  times. 

tory  is  unimportant,  except  that  it  points  out  the  way  of  prevention 
— thorough  cooking  of  all  meat. 

Tenia  saginata,  or  beef  tapeworm,  is  perhaps  the  most  common  and 
reaches  a  length  of  ^8  m.  (12-24  feet).  The  head  is  2-2l^  mm. 
wide  and  has  four  suction  apparatuses.  The  neck  is  only  a  few  milli- 
meters long;  hence  the  segmentation  begins  much  sooner,  and  each 


EXAMINATION   OF   FECES 


189 


segment  has  a  lateral  uterine  canal  and  a  uterus  made  up  of  seventeen 
to  thirty  fine  branches  opening  into  it.  These  segments  pass  through 
the  anus  of  the  host  without  the  passage  of  feces,  making  autonomic 
movements.  The  eggs  are  round  or  oval,  with  the  shell  marked  by 
lines  arranged  radially,  and  the  embryo  has  six  hooks.  Man  acquires 
this  parasite  from  both  the  flesh  of  the  ox  and  the  goat.  When  frag- 
ments of  such  a  worm  are  found  and  one  is  in  doubt  as  to  its  character, 


Fig.  44. — Tenia  solium,  showing  egg  of  same  enlarged  four  hundred  times. 


or  when  the  patient  states  that  such  fragments  have  been  passed,  par- 
ticularly in  ambulatory  practice,  it  is  often  most  conducive  to  haste  in 
diagnosis  to  wash  out  the  colon  of  the  patient  with  a  rectal  tube,  when 
often  these  segments  may  be  found,  white  and  free  from  fecal  matter. 
Placed  between  two  microscopic  slides,  pressed  rather  firmly  together, 
and  then  examined  with  the  naked  eye  or  with  a  reading  glass,  the 
lateral  uterine  opening  can  be  distinguished  and  the  network  of 
genital  canals,  which  by  their  greater  number  distinguishes  this  from 


190  DISEASES   OF   THE   DIGESTIVE   TRACT 

the  tenia  solium.     The  head  requires  a  greater  magnification  for  clear 
discernment,  but  the  power  should  always  be  low. 

Tenia  Solium. — Tenia  solium  is  fortunately  much  less  common, 
since  meat  inspection  has  been  more  rigid  under  the  control  of  the 


Fig.  45. — Segment  of  Tenia  solium,  enlarged  twelve  times. 

government.  Still,  we  hear  of  outbreaks  among  our  foreign  popula- 
tion on  account  of  their  fondness  for  uncooked  ham  and  sausage,  but 
that  not  every  one  who  insists  on  the  thorough  cooking  of  meat  is  free 
from  it  is  evidenced  by  the  death  of  a  veterinary  and  official  inspector 


EXAMINATION   OF  FECES  191 

of  meats  in  Westphalia  from  trichinosis,  acquired  from  pork  killed 
within  his  own  jurisdiction  and  presumably  which  he  himself  had  in- 
spected. This  variety,  which  attains  a  length  of  only  2-3  m.  (6-9 
feet),  is  derived  wholly  from  eating  pork.  Its  head  is  not  larger  than 
that  of  a  pin  and  has  four  sucking  appliances,  and  a  rostellum  armed 
with  hooks  in  the  middle  of  the  head.  The  neck  has  a  length  of  only  1 
cm.  and  is  very  small.  The  segments  have  also  a  lateral  genital  open- 
ing, like  the  saginata,  but  fewer  (7-10),  much  larger,  and  to  the  naked 
eye  a  coarser  network  of  canals  connected  with  it.  They  are  usually 
discharged  in  long  ribbons  and  with  the  stool,  while  the  eggs  look  much 
like  the  beefworm.  These  are  the  only  varieties  of  the  tapeworm  that 
are  at  all  common  in  our  country ;  the  others,  botriocephalus  latus,  de- 
rived from  fish,  and  tenia  nana,  are  curiosities. 

Round  Worms. — The  round  worms  have  as  chief  representatives  of 
their  kind,  and  the  one  most  commonly  met,  the  Ascaris  lumbricoides, 
whose  habitat  is  the  duodenum,  but  which  migrates  to  the  stomach,  and 
by  vomiting  reaches  the  esophagus  and  often  the  nose.  This  is  the 
worm  of  which  the  mother  has  the  greatest  fear,  and  to  which  she 
ascribes  every  attack  of  indigestion  which  the  child  may  have.  The 
eggs  are  freely  discharged  in  the  feces,  are  oval  and  inclosed  in  a  trans- 
parent shell,  surrounded  by  a  layer  of  albumin;  this  outer  layer  is 
often  stained  brown  from  feces.  There  are  two  sexes,  the  male  reach- 
ing a  length  of  15-20  cm.,  and  the  female  25-40  cm.  Fairly  good  speci- 
mens were  once  found  by  the  author  in  the  stomach  of  a  young  man,  a 
suicide  from  cyanide,  at  the  autopsy,  and  his  friends  derived  great 
comfort  from  the  thought  that  their  (the  worms)  presence  had  con- 
tributed to  the  depression  which  led  to  this  rash  act. 

Oxyuris  Vermicularis. — The  oxyuris  vermicularis,  or  pinworm,  is 
thread-like,  and  the  male  has  a  length  of  3-5  mm.  and  the  female  10-12 
mm.  Its  habitat  is  the  upper  portion  of  the  colon,  but  it  wanders  to 
the  anus,  and  in  young  girls  to  the  vagina,  there  producing  an  intense 
itching,  and  in  female  children  often  a  leucorrhea.  The  eggs  are  not 
found  in  the  stool  itself,  but  can  be  readily  obtained  by  wiping  the 
skin  around  the  anus  with  a  wad  of  cotton.  The  eggs  are  of  irregular 
shape,  like  a  bean,  and  have  a  thin  envelope.  They  are  occasionally 
found  in  the  appendix,  but  are  not  always  to  be  regarded  as  the  cause 
of  appendicitis. 

Ankylostoma  Duodenale. — Ankylostoma  duodenale,  a  variety  of 
which  is  known  to  us  as  the  "hookworm"  or  necator  Americanus,  has 
come  to  have  a  much  greater  significance  for  us  since  a  knowledge 
of  its  prevalence  through  the  South  has  been  brought  to  us  by  the 


192 


DISEASES   OF   THE   DIGESTIVE    TRACT 


Fig.  46. — Pinworm   (Oxyuris  vemiicu]aris),  natural  size. 


Fig.  47. — Egg  of  pinworm,  enlarged  twelve  hundred  times. 


EXAMINATION   OP    FECES 


193 


Fig.  48. — Hookworm  ( Ankylostoma  duodenale),  natural  size. 


Fig.  49. — Egg  of  hookworm,  sliowing  segmentation,  enlarged  twelve  hundred  times. 


194  DISEASES   OF   THE   DIGESTIVE   TRACT 

labors  of  Allen  J.  Smith  and  Charles  W.  Stiles.  The  worm  fastens 
itself  with  its  sharp  hooks  to  the  mucous  membrane  of  the  small  in- 
testine, and  not  solely  to  the  duodenum,  as  its  name  would  indicate, 
and  by  sucking  the  blood,  at  the  same  time  injecting  a  poison  of  its 
own  secretion,  produces  true  anemia.  The  eggs  are  oval,  have  a  hard 
shell,  and  contain  an  embryonic  cell,  which  has  undergone  partial  seg- 
mentation. They  are  eliminated  in  enormous  numbers  Avith  the  stool, 
which,  when  kept  warm,  allows  them  to  develop  into  larvae.  The  infec- 
tion occurs  through  the  mouth  or  through  the  skin.  According  to 
Stiles  the  chief  cause  of  infection  in  the  South  is  the  carelessness  in  the 
disposal  of  the  stools,  with  M'hich  the  soil  becomes  impregnated,  and 
the  barefooted  natives  easily  acquire  them  through  the  skin. 

Trichinosis  Spiralis. — The  trichinosis  spiralis,  though  occasionally 
found  in  the  stool,  is  so  rare  that  it  has  no  clinical  significance  as  a  con- 
stituent of  the  feces. 


CHAPTER  VII 

DIETETICS  IN  DIGESTIVE  DISORDERS 

General  dietetic  principles  have  been  evolved  from  observations 
made  on  the  time  during  which  various  foods  remain  in  the  stomach, 
on  their  state  of  digestion  when  withdrawn  at  certain  intervals,  and 
their  utilization  as  determined  by  the  residue  in  the  feces.  For  in- 
stance, by  the  first  method  we  know  that  fat  meat  leaves  the  stomach 
much  more  slowly  than  lean  or  than  meat  cooked  in  fat,  as  250  grams 
of  boiled  lean  beef  leave  the  stomach  in  three  to  four  hours,  but  the 
same  amount  of  roast  goose  demands  four  to  five  hours ;  by  the  sec- 
ond method  we  learn  that  beefsteak  is  dissolved  in  three  hours,  while 
pork  requires  four  hours;  and  by  the  last  method  we  learn  that  the 
cellulose  of  vegetables  and  the  connective  tissue  (tendons,  arteries, 
etc.)  of  meat  are  the  most  difficult  to  convert  into  an  absorbable 
product.  Particular  forms  of  diet  may  be  used  for  diagnosis,  as  in 
the  test  diet  for  intestinal  functions ;  or  the  use  of  nuts,  coarse  grains, 
and  the  cabbage  group,  as  recommended  by  Kelling,  for  exaggerating 
the  symptoms  in  stenosis  of  the  intestine,  and  by  others  to  procure  a 
mild  hemorrhage  in  chronic  ulcer  of  the  stomach  and  the  duodenum; 
or  for  therapeutic  purposes,  as  in  the  restriction  of  the  patient  from 
excessive  use  of  meat  in  gastric  hypersecretion;  or  the  insistence  on 
finely  divided,  if  not  liquid  food,  in  pyloric  stenosis.  Above  all  things, 
we  must  insist  on  quantity,  for  these  patients  with  digestive  disorders 
are  undernourished  from  fear  of  food,  or  because  it  causes  discomfort, 
much  oftener  than  from  any  inability  of  the  digestive  organs  to  dis- 
pose of  it.  So  far  we  have  been  between  the  two  types  or  schools 
of  dietetitians,  one  of  which,  following  Abernethy's  old  dictum  to  an 
overanxious  patient,  "Eat  the  shovel  and  tongs,  madam,  but  do  not 
bother  me, ' '  has  always  advised  loosely,  milk,  gruel,  and  beef  tea,  and 
in  one  case  which  was  seen  in  consultation,  a  tuberculay  enteritis, 
wasted  to  the  last  degree  of  emaciation,  the  physician  in  charge  told 
the  author  that  the  sufferer  was  getting  plenty  of  nourishment  be- 
cause he  was  partaking  of  popcorn  water  freely ;  and  the  other  school, 
which  would  have  a  patient  equipped  at  table  with  knife,  fork,  plate, 
cup,  and  a  pair  of  scales,  with  which  every  morsel  should  be  carefully 

195 


196  DISEASES  OF   THE   DIGESTIVE   TRACT 

weighed,  with  due  reference  to  calories,  protein,  carbohydrates,  and 
fat.  Such  an  effort  for  scientific  accuracy  will  probably  be  confined 
to  hospital  wards,  and,  while  the  profession  is  vastly  benefited  by  the 
results  obtained  in  such  magnificent  equipments  as  that  of  the  von 
Noorden  clinic  at  Vienna,  we  shall  have  to  pursue  some  middle  course, 
more  adapted  to  the  facilities  of  our  patients;  indeed,  such  a  one  has 
been  devised  from  the  excellent  tables  of  Atwater,  who  has  analyzed 
the  foods  as  prepared  for  the  table,  and  Arnold,  who  has  adopted  the 
old  measures  which  have  served  us  for  centuries  in  administering  medi- 
cines— the  teaspoon,  the  tablespoon,  and  wine  glass,  a  piece  the  size 
of  a  pea,  etc.  Granted  that  it  is  not  accurate  in  this  time  and  age,  we 
are  beginning  to  appreciate  "near  silk"  when  we  cannot  have  the 
real  article.  These  suggestions  in  regard  to  the  diet  in  various  dis- 
orders take  into  consideration  what  is  of  benefit  to  the  patient — not 
what  he  thinks  is  of  benefit — and  will  often  have  to  be  modified  to  meet 
idiosyncrasies  as  to  food.  One  says,  "Milk  makes  me  constipated"; 
'another,  "Eggs  make  me  bilious";  while  a  third  declares  that  cream 
produces  a  "sour  stomach."  In  such  eases  all  arguments  fail,  and 
one  will  simply  have  to  exclude  them  from  the  diet  prescribed  and 
substitute  an  equivalent  in  caloric  value. 

PROPHYLAXIS. 

Prophylaxis  in  modern  times  is  becoming  more  and  more  the  func- 
tion of  the  practitioner,  as  well  as  that  of  the  public  health  officer, 
and,  while  such  a  work  as  this  should  be  devoted  to  the  treatment  of 
digestive  disorders,  a  few  words  can  be  well  devoted  to  prevention.  It 
has  been  found  that  the  breast-fed  infant  usually  prospers  far  beyond 
his  unfortunate  artificially-fed  companion,  but,  even  after  solid  food 
begins  to  be  taken,  the  former  still  has  the  advantage  in  freedom  from 
digestive  disturbances.  Still,  young  children  are  simply  a  species 
of  young  animal,  and,  unless  closely  watched,  devour  their  food  as 
their  prototypes  do,  with  disastrous  results.  Many  a  patient  says,  "I 
have  had  stomach  trouble  all  my  life,  even  as  a  child  I  suffered, ' '  and, 
apart  from  congenital  enteroptoses,  one  can  usually  assure  himself 
that  such  a  one  belonged  to  the  numerous  band  of  "bolters"  almost 
from  birth.  During  childhood  the  abused  and  insulted  digestive  or- 
gans submit  for  a  period  to  the  indignity  of  "bolted"  food,  and  then 
comes  the  storm  in  the  form  of  a  so-called  * '  bilious  attack ' ' ;  three  days 
of  vomiting  and  inability  to  take  food,  attributed  always  to  the  last 
article  of  food  taken  before  the  revolution,  recovery,  and  another  on- 


DIETETICS  IN   DIGESTIVE  DISORDERS  197 

slaught  on  the  patience  and  indulgence  of  the  stomach.     No  parent 
should  neglect  the  teeth  of  his  child,  insisting  on  the  use  of  a  tooth- 
brush, and  consulting  a  dentist  or  a  dental  clinic  when  the  child  com- 
plains of  toothache,  which  often  means  decayed  teeth.     The  admirable 
attention  paid  to  the  teeth  of  pupils  in  our  city  schools  by  the  school 
dentists  could  well  be  imitated  by  the  rural  schools  rather  than  some 
of  the  frills  of  education  which  the  latter  ape.     Furthermore,  un- 
cleanly teeth,  covered  with  decomposing  food  fragments,  cause  fetor 
of  the  breath,  which  is  often  perceptible  to  the  patient,  diminishing  the 
appetite,  and  producing  objectively  many  of  the  peculiar  tastes — 
sour,  bitter,  etc. — of  which  patients  complain,  as  well  as  providing  a 
host  of  organisms  which  make  their  way  into  the  stomach  when  food 
is  swallowed.     A  coated  tongue  may  also  interfere  with  the  delicate 
sense  of  taste  which  has  been  proven  so  essential  for  a  free  flow  of 
gastric  juice,  and  many  patients  declare  that  brushing  the  tongue,  also 
with  the  aid  of  some  antiseptic  mouth-wash,  improves  taste  and  appe- 
tite.    The  importance  of  slow  eating  and  good  mastication  has  already 
been  emphasized,  but  the  best  means  to  accomplish  this  is  usually  left 
to  the  patient.     Many  a  one  has  devised  such  methods  as  laying  down 
the  knife  and  fork  after  each  mouthful,  placing  the  watch  beside  the 
plate  and  seeing  to  it  that  twenty  minutes  at  least  are  employed  in 
the  act  of  eating,  or  reading  a  book  or  paper  at  meals,  to  accomplish 
this   purpose.     Cheerful   companionship    and   lively   conversation   at 
mealtime,  it  is  true,  improves  digestion  by  stimulating  the  flow  of  di- 
gestive juices,  but,  in  the  course  of  lively  conversation,  eating  unfor- 
tunately only  too  often  keeps  pace  with  the  rapid  flow  of  thought,  so 
that  many  of  our  public  men  are  victims  of  the  numerous  state  dinners 
thrust  upon  them.     Not  only  does  good  mastication  produce  copious 
saliva,  but  a  free  flow  of  this  has  also  been  proven  to  cause  a  more 
abundant  secretion  of  gastric  juice.     Condiments  also  are  known  to 
stimulate  the  flow  of  the  former  and  probably  also  the  latter;  hence 
care  should  be  taken  in  their  use  whenever  hypersecretion  is  present. 
The  avoidance  of  eating  when  excessively  weary,  angry,  sad,  or  fright- 
ened explains  itself,  for,  curiously  enough,  food  taken  in  such  a  state 
of  mind  may  produce  epigastric  distress   and  sometimes  vomiting. 
This  may  be  due  to  loss  of  appetite  at  such  a  time,  a  factor,  as  Pawlow 
has  shown  us,  of  great  importance  in  aiding  digestion.     That  one 
should  eat  at  regular  intervals  has  been  taught  for  ages,  and  it  is  as 
true  today  as  ever;  every  one  has  experienced  the  sensation  of  "out- 
staying the  appetite,"  and  the  indifference  with  which  food  is  taken 
when  the  customary  meal  time  is  deferred,  and  the  subjectively,  at 


198  DISEASES   OP   THE   DIGESTIVE   TRACT 

least,  sluggish  digestion  which  follows.  We  can  all  agree  with  the  re- 
frain of  the  popular  song,  "I  eat  when  I  am  hungry,"  but  this  does 
not  excuse  the  impotence  of  refraining  utterly  from  food  when  appe- 
tite is  not  present.  There  is  some  question  as  to  when  the  heavy 
meal  of  the  day  is  to  be  taken.  The  German  sticks  to  the  middle  of 
the  day,  but  anyone  w^ho  has  attempted  to  enter  a  German's  place  of 
business  between  1  and  3  o'clock  in  the  afternoon  will  find  that  there 
is  a  justification  for  this  hour  in  the  two  hours  taken  from  business 
for  its  digestion.  With  us  the  evening  proves  the  better  hour, 
for  the  business  cares  are  over  for  the  day  and  digestion  can 
take  place  in  peace  and  quietude.  The  employment  of  the  five- 
meal  schedule  daily  has  served  the  author  very  satisfactorily  where 
the  patient  was  undernourished,  and  where  impaired  motility 
compelled  small  meals  which  the  stomach  could  readily  dispose  of 
and  pass  on  to  the  intestine,  while  three  meals,  copious  enough  to 
keep  the  nutrition  at  par,  were  very  much  delayed  in  their 
departure  from  the  organ,  causing  distress  and  often  pain,  which  was 
promptly  allayed  by  the  lesser  meal.  Corsets,  by  their  compression  of 
the  liver,  and  secondarily  of  the  stomach,  particularly  at  mealtime  and 
during  digestion,  impair  very  decidedly  the  motility  of  a  weakened 
stomach.  As  long  as  fashion  decrees  they  shall  be  worn,  we  should  at 
least  recommend  their  loosening  or  removal  at  mealtime.  Another  in- 
jurious feature  of  our  habits  is  the  extreme  heat  of  many  articles  of 
food.  For  instance,  soup,  which  is  often  taken  at  a  temperature  to 
which  we  would  hesitate  to  subject  our  hands,  will  soon  cause  a  mild 
gastric  catarrh.  The  temperature  of  no  food  should  be  above  that  of 
the  body — 98.8°  F.  Then,  again,  there  is  a  vicious  habit  of  drinking 
ice-water  before  a  meal,  which  a  waiter  always  provides  before  he  does 
food.  It  has  been  proven  that  it  takes  half  an  hour  after  a  glass  of 
ice-water  to  restore  the  temperature  of  the  stomach  to  the  optimum 
for  active  digestion.  Persistent  drinking  of  ice-cold  sodas  on  an  empty 
stomach  will  also  ruin  a  weak  digestion.  Drinking  at  mealtime  should 
be  avoided,  not  because  it  dilutes  the  gastric  juice,  as  was  formerly 
supposed,  for  we  know  that  fluids  course  along  the  lesser  curvature 
and  promptly  leave  the  stomach,  but  because  it  aids  hasty  eating  and 
imperfect  mastication,  since  water  or  other  beverage  is  made  to  take 
the  place  of  saliva  in  aiding  deglutition.  Many  have  tried  to  deter- 
mine whether  it  is  better  to  eat  and  rest  or  eat  and  run,  and  at  present 
opinion  is  divided.  If  we  may  follow  the  custom  of  animals,  which 
seem  to  enjoy  an  excellent  digestion,  we  will  take  our  "forty  winks" 
after  a  hearty  meal,  for  "tired  nature's  sweet  restorer"  certainly 


DIETETICS   IN   DIGESTIVE  DISORDERS  199 

presses  on  us  with  insistent  force  at  such  a  time,  and  dowagers  rarely 
refrain  even  after  state  dinners.  AVegele  recommends  that  those  pa- 
tients— chiefl}^  nervous  dyspeptics — who  awaken  from  a  nap  after  a 
meal  with  a  spinning  head  or  even  a  headache,  great  lassitude,  and  a 
bad  taste  in  the  mouth,  should  take  a  short  walk  after  eating  and 
then  lie  down.  With  patients  suffering  from  impaired  gastric  motility 
there  can  be  no  question  of  the  advantage  gained  by  lying  on  the  right 
side  for  thirty  minutes  after  a  meal;  whether  asleep  or  not  makes 
but  little  difference.  Sufferers  from  gastric  ulcer,  however,  often 
claim  to  suffer  more  pain  when  lying  on  the  right  side  than  when  on 
the  left,  or  sitting  up.  It  has  been  the  author's  experience  that  much 
may  be  gained  by  inducing  the  patient,  if  possible,  to  rest  or  sleep  a 
short  time  before  the  meal,  particularly  when  weary.  Sleep  is  fully 
as  essential  as  diet  in  digestive  disorders,  particularly  those  associated 
with  loss  of  flesh,  for  during  sleep  metabolism  is  very  much  delayed; 
in  fact,  insomnia  is  one  of  the  most  distressing  symptoms  of  the  dis- 
order known  as  gastric  neurosis.  Excessive  use  of  tobacco  lessens  the 
appetite  and  apparently  produces  gastric  hypersecretion;  hence  smok- 
ing should  never  be  allowed  on  an  empty  stomach,  but  after  the  meals 
smoking  seems  to  aid  digestion,  or  else  our  grandmothers  were  mis- 
taken, many  of  whom,  when  old,  smoked  an  after-dinner  pipe  and 
claimed  that  it  overcame  the  discomforts  of  digestion  arising  from 
senile  dyspepsia.  It  is  generally  accepted  that  during  menstruation 
the  digestion  is  retarded;  hence  at  this  time  no  gastronomic  feats 
should  be  undertaken,  and  recurrence  of  partially  cured  gastric  dis- 
orders should  not  discourage  either  physician  or  patient.  Constipa- 
tion should  never  be  neglected,  for  patients  are  numerous  who  never 
have  digestive  discomfort  except  when  two  or  three  days  elapse  with- 
out stool. 

CHARACTER  OF  FOODS. 

The  character  and  composition  of  foods  for  dietetic  purposes  must 
be  studied  along  three  lines — ease  of  digestion,  readiness  of  departure 
from  the  stomach,  and  nutritive  content.  For  instance,  the  old-time 
beef  tea  and  many  commercial  food  preparations  fulfilled  the  former 
conditions,  but  not  the  last;  cream  the  last,  but  not  the  former.  As 
to  whether  any  particular  kind  of  food  causes  more  or  less  painful 
sensation,  apart  from  the  form  (coarse  or  hilly  divided)  in  which  it  is 
taken,  is  difficult  to  say.  Subjectively,  which  is  the  only  way  to  settle 
this  point,  and  for  which  we  have  to  rely  on  the  patient,  sufferers 
from  cancer  and   achylias  declare  that  meat   causes  more  distress, 


200  DISEASES   OF    THE    DIGESTIVE    TRACT 

while  those  suffering  from  impaired  motility  declare  that  fats  cause 
them  most  discomfort.  Our  views  hitherto  in  regard  to  the  digesti- 
bility of  food  have  been  acquired  and  confined  almost  wholly  to  its 
digestion  in  the  stomach,  but  from  study  of  the  fluid  containing  casein 
and  meat  fragments,  passing  from  a  duodenal  fistula  we  have  learned 
that  vastly  more  digestion  takes  place  in  the  intestine  than  is  sup- 
posed. 

LIQUID  NOURISHMENT. 

Liquid  nourishment  is  usually  chosen  where  the  digestive  func- 
tions are  weakened,  and  the  simplest  of  this  group  is  water,  reinforced 
by  some  ingredient  having  actual  nutrient  value,  like  egg  albumin, 
milk  sugar,  or  many  of  the  dextrine  and  peptone  preparations  on  the 
market,  like  laibose,  liquid  malt,  etc.  These  preparations  serve  a  need, 
but,  unless  the  miracle  of  the  loaves  and  fishes  is  to  be  repeated,  as  is 
claimed  by  some  of  the  manufacturers,  semistarvation  will  always  ac- 
company their  exclusive  use,  for  their  caloric  value  is  so  low,  when 
diluted  as  recommended,  that  quarts  must  be  swallowed  to  obtain 
2,000-3,000  calories  daily.  While  water  is  supposed  to  promptly  leave 
the  normal  stomach,  there  is  considerable  doubt  expressed  as  to 
whether  this  is  true  of  the  atonic  stomach,  which,  as  can  be  shown 
by  percussion  in  an  erect  position,  sags  badly  after  a  couple  of  glasses 
of  water,  so  that  such  persons  should  be  warned  against  any  excess 
of  water  drinking  or  other  fluid  at  any  one  period.  As  a  rule,  one 
glass  at  a  time  is  all  that  should  be  taken. 

Carbonated  waters  incite  peristalsis,  and  undoubtedly  have  a  mildly 
anesthetic  effect  on  a  hypersensitive  stomach.  When  mixed  with  the 
syrups,  egg,  etc.,  at  our  soda  fountains,  if  not  too  cold,  the  mixture 
makes  an  admirable  adjuvant  to  our  three-meal  schedule  when  the 
patient  is  undernourished.  Of  course  absolute  purity  of  materials 
(including  the  calcium  carbonate  and  sulphuric  acid)  must  be  insisted 
on,  and,  if  such  guarantee  is  not  furnished,  soda-water  had  best  be 
avoided.  The  custom  of  overcharging  natural  soda-waters  should  be 
reprehended,  for  White  Kock  has  been  so  heavily  charged  that  it  really 
caused  unpleasant  sensations  and  harmful  effects  in  gastric  disturb- 
ances, and  it  is  the  author's  belief  that  it  might  cause  rupture  of  a 
vessel  if  its  coats  were  impaired.  To  avoid  any  danger  of  this  sort, 
all  that  is  necessary  is,  of  course,  to  allow  some  of  the  gas  to  escape 
before  drinking. 

Milk,  considered  theoretically,  should  be  the  ideal  food,  since  it  con- 
tains fat,  carbohydrate,  and  protein  in  proper  proportions  to  meet  the 


DIETETICS  IN   DIGESTIVE   DISORDERS  '201 

wants  of  the  body.  On  account,  however,  of  its  low  nutritive  content 
(approximately  12  per  cent),  it  requires  at  least  3  liters  daily  to  sup- 
ply the  needs  of  the  ordinary  individual,  of  which  over  214  liters  are 
water ;  hence,  on  account  of  its  volume,  it  puts  too  great  a  burden  on  a 
weakened  stomach.  With  impaired  motility,  any  physician  who  pre- 
scribes a  diet  of  3  to  4  liters  of  milk  daily  should  first  take  it  himself 
for  a  short  time.  For  the  adult,  too,  there  is  great  diminution  in 
utilization,  as  10  per  cent  of  the  nutriti'v^e  material  appears  in  the 
stools.  Then,  we  have  the  unavoidable  changes  in  the  individual 
variations  in  the  fineness  of  coagulation  of  the  milk  taken.  Many 
times  after  a  meal  of  milk  such  huge  masses  of  curd  are  found  that  the 
lumen  of  a  12-mm.  tube  may  be  stopped.  This  difficulty  may  be  over- 
come by  taking  it  in  teaspoonful  amounts,  or  by  adding  to  milk,  soda, 
or  lime-water,  any  of  the  commercial  foods  recommended  for  this  pur- 
pose, or  merely  well-toasted  bread  as  croutons  ground  up  in  a  coffee 
mill  and  added  in  the  proportion  of  a  teaspoonful  to  a  glass  of  milk. 
To  overcome  the  disadvantage  of  volume,  one  can  use  thin  (20  per 
cent)  cream,  one  tablespoonful  of  which  gives  the  same  caloric  value 
as  a  glass  of  the  whole  milk.  On  the  whole,  however,  an  exclusive 
milk  diet  with  most  individuals  is  a  species  of  undernourishment — 
as  a  facetious  young  patient  of  the  author's  calls  it,  a  "thin  as  a  pin" 
cure.  It  may  do  fairly  well  for  patients  in  bed,  but,  as  soon  as  active 
life  begins  again,  there  is  a  nitrogen  loss  and  muscular  weakness,  which 
is  largel}^  dependent  on  the  fact  that  the  weakened  digestive  organs 
are  restricted  in  their  absorptive  power  for  milk,  and  the  volume  or 
residue  in  the  feces  increases  as  the  amount  of  milk  taken  becomes 
greater  beyond  a  certain  limit;  hence  we  confine  the  use  of  the  ex- 
clusive milk  diet  to  acute  inflammatory  diseases  of  the  tract  on  patients 
confined  to  the  bed.  One  thing  is  certain,  that  a  not  too  extended  em- 
ployment of  exclusive  milk  diet  will  check  putrefactive  processes  in  the 
intestine — whether  due  to  the  sugar  of  milk  or  the  casein,  we  do  not 
know — and  relieve  the  patient  of  many  of  his  neuralgic  symptoms,  but 
whether  arising  from  the  putrefaction  is  uncertain.  Of  course  there 
is  milk  and  milk.  When  patients  assure  you  that  they  cannot  take  milk, 
always  make  inquiry  with  reference  to  the  source  of  the  milk.  Many 
an  individual  will  on  a  succeeding  day  take  a  certified  milk  with  com- 
fort when  on  a  preceding  day  an  inferior  milk  was  rejected  by  the 
stomach.  Milk  is  best  for  invalids  when  lightly  cooked,  or  "soft 
boiled,"  as  we  say  of  an  egg  that  is  cooked  three  minutes.  This  de- 
stroys any  organisms  which  may  be  present  and  makes  it  more  di- 
gestible, so  the  best  authorities  state.     Practically  all  the  milk  we  now 


202  DISEASES   OF   THE   DIGESTIVE   TRACT 

receive  is  "pasteurized,"  which  does  not  seem  to  interfere  with  its  di- 
gestibility, while  the  former  method  of  "sterilization"  did  most  em- 
phatically convert  the  protein  into  a  modification  difficult  of  digestion. 
"We  can  readily  increase  the  nutritive  value  of  milk  by  adding  to  it 
sugar  of  milk  (a  tablespoonful  to  a  glass),  milk  powder  made  by  evapo- 
ration and  grinding  up  the  residue,  or  even  condensed  milk  can  be 
added  with  profit  to  whole  milk.  All  these  remarks  as  to  the  disad- 
vantages of  the  milk  diet  apply  to  it  when  milk  is  employed  ex- 
clusively ;  when  used  as  an  adjuvant  to  a  mixed  diet,  that,  as  Kipling 
says,  is  "another  story."  One  of  the  author's  most  valuable  aids  in 
all  diets  is  the  midf orenoon,  midafternoon,  and  bedtime  glass  of  milk, 
and  never  under  such  conditions  have  the  stools  revealed  any  signifi- 
cant milk  residue.  The  attractive  way  in  which  such  a  glass  of  milk 
can  be  put  up  at  the  soda  fountains  has  been  mentioned,  but  those  who 
have  a  distaste  for  milk  can  readily  add  to  it  a  little  coffee,  tea, 
powdered  chocolate,  or  some  good  vanilla  extract,  which  makes  it  more 
palatable.  Furthermore,  it  is  rare  that  anyone  can  be  found,  no 
matter  how^  great  his  distaste,  who  will  not  take  his  portion  of  milk 
in  the  form  of  ice  cream. 

Condensed  milk  for  any  other  purpose  than  above  mentioned  is  un- 
suitable for  most  impaired  digestions  on  account  of  the  readiness  with 
which  it  will  ferment  because  of  the  added  sugar. 

A  preserved  or  canned  milk  without  the  addition  of  sugar,  prepared 
by  the  Borden  firm,  is  on  the  market,  and  extremely  palatable.  On  a 
twenty-one  day  trip  from  Galveston  to  Bremen  the  steamer  carried 
only  this  milk,  and  there  were  no  complaints. 

Buttermilk  contains  less  fat  and  milk  sugar  than  whole  milk,  but 
contains  0.4  per  cent  lactic  acid.  A  glass  of  this  contains  only  80 
calories,  while  one  of  whole  milk  contains  160.  On  the  contrary,  how- 
ever, buttermilk  is  much  more  digestible,  and  has  been  recommended 
by  various  authorities  for  fever  and  gastric  ulcer,  and  it  is  the  author's 
preference  for  feeding  those  jaundiced.  It  certainly  stimulates  in- 
testinal peristalsis,  and,  according  to  Metschnikoff,  by  inhibiting  putre- 
factive changes  in  the  colon  prevents  arteriosclerosis,  so  that  the  catch 
phrase  of  one  of  our  large  milk  contractors,  found  over  its  stores  and 
wagons,  is,  * '  Drink  buttermilk  and  live  forever. ' '  When  one  does  not 
live  where  buttermilk  can  be  easily  procured,  small  separators  are 
made  for  household  purposes  to  remove  the  fat,  or  the  old  method  of 
standing  milk  until  the  cream  separates  may  be  employed.  Indis- 
criminate souring  is  not  so  advantageous  as  the  use  of  the  Bulgarian 
bacillus,  which  makes  the  so-called  "joghourt"  and  indiscriminate 


DIETETICS   IN   DIGESTIVE  DISORDERS  203 

fermentation  introduces  various  kinds  of  organic  acids  in  addition  to 
the  lactic.  It  must  be  observed  that  two  purposes  are  served  by 
the  use  of  buttermilk — the  introduction  of  lactic  acid  and  the  elimina- 
tion of  fat  from  the  diet.  When,  however,  whole  milk  is  sim- 
ply diluted  and  fermented,  as  recommended  by  the  manufacturers  of 
some  lactic  acid  tablets,  the  former  purpose  is  satisfied,  but  not  the 
latter. 

Sour  milk,  for  reasons  stated  above,  is  not  as  good  as  buttermilk. 
Still,  when  first  coagulated  and  beaten  to  break  up  the  curds,  it  is  not 
only  an  easily  digested  mixture,  but  much  enjoyed  by  many  people. 
When,  however,  the  fat  is  retained,  it  is  much  less  likely  to  be  well 
borne. 

Whey  can  have  but  little  claim  as  a  food  on  account  of  its  minimum 
caloric  value,  but  from  its  milk  sugar  content  it  forms  an  excellent  bev- 
erage. The  author's  preference,  however,  is  to  provide  patients  with 
milk  sugar  and  let  them  make  a  substitute  by  adding  a  dessertspoonful 
(approximately  10  grams)  to  a  glass  of  water  (approximately  240  c.c), 
which  makes  it  a  little  less  concentrated  than  the  natural  product  (4.1 
per  cent  instead  of  4.81  per  cent). 

Koumiss  and  kefir,  the  former  of  which  made  from  cow's  milk  can 
be  obtained  at  many  drug  stores,  are  allied  to  buttermilk,  but  not  the 
same.  Both  of  these  are  alike  in  having  the  greater  part  of  their 
lactose  converted  to  carbon  dioxide,  alcohol,  and  lactic  acid.  The 
casein  also  is  converted  by  this  process  of  fermentation  into  peptone- 
like bodies.  This  koumiss  tastes  distinctly  sour,  is  an  intoxicant  in 
large  quantities,  and  acts  as  an  excellent  diuretic.  When  fermented 
only  one  day,  this  preparation  is  a  laxative;  when  two  days,  is  indif- 
ferent; and  when  three  days,  is  slightly  constipating.  Koumiss  and 
kefir  are  said  to  be  contraindicated  when  there  is  a  tendency  to  apo- 
plexy, gastric  ulcer,  and  pulmonary  hemorrhage.  With  these  restric- 
tions, no  better  food  could  be  devised,  since  the  carbon  dioxide  acts 
as  a  mild  anesthetic  and  stimulator  of  gastric  motility ;  the  lactic  acid 
checks  intestinal  putrefaction,  the  casein  is  converted  into  a  material 
much  resembling  the  protein  of  breast  milk,  and  the  small  amount  of 
alcohol  stimulates  digestion.  Fortunately  for  our  patients,  koumiss 
from  cow's  milk  can  be  procured  from  many  of  the  large  milk  dealers 
and  is  delivered  daily,  but,  as  the  name  was  first  applied  to  mare's 
milk,  it  is  a  question  for  the  United  States  Agricultural  Bureau  to  de- 
termine whether  it  is  misbranded. 

Tea  and  coffee  belong  to  the  group  of  condiments,  and  have  no  nutri- 
tive value  except  when  taken  with  cream  and  sugar.     It  is  always  easy 


204  DISEASES   OF   THE   DIGESTIVE   TRACT 

to  induce  patients,  whose  digestion  will  allow  them,  to  take  with  each 
cup  of  coffee  one  tablespoonful  of  cream  and  at  least  a  teaspoonful  of 
sugar,  by  which  each  cup  attains  a  caloric  value  of  63,  an  amount  not 
to  be  disregarded  in  undernourished  patients.  Dyspeptics,  however, 
often  complain  of  disagreeable  sensations  after  a  cup  of  coffee,  and 
these,  taken  in  connection  with  the  alarming  advertisments  of  the  dan- 
gers of  coffee  by  the  manufacturers  of  substitutes  for  that  beverage, 
keep  the  patient  in  a  state  of  terror  for  fear  of  "coffee  heart"  and 
various  other  fictitious  ills.  In  his  clinic.  Boas  used  often  to  say  to  a 
patient,  "Take  tomorrow  morning  your  usual  portion  of  black  coffee, 
the  next  day  the  cream  with  hot  water,  and  the  next  the  sugar  with 
hot  water,  and  then  report  which  causes  your  unpleasant  sensations," 
and  verj'  often  it  was  not  the  coffee  at  all.  It  may  be,  of  course,  that 
some  individuals  are  unfavorably  affected  by  the  volatile  substance 
(caffeol)  which  develops  by  roasting  the  coffee  bean  and  acts  on  the 
nervous  system ;  but,  coffee  or  not,  the  morning  is  always  a  doleful 
period  for  the  nervous  dyspeptic,  and  he  is  prone  to  ascribe  his  un- 
pleasant sensations  to  the  cup  of  coffee.  Actually,  however,  coffee  acts 
as  a  stimulus  to  motility  of  the  stomach,  and,  outside  of  damaged 
hearts,  where  it  increases  the  heart  beats  unduly,  gastric  hypersecre- 
tion, which  it  increases,  and  diarrhea,  w^hich  is  exaggerated  by  it,  it 
has  never  been  the  author's  experience  to  see  any  harm  arising  from 
the  morning  cup  of  coffee,  if  taken  after  the  breakfast  and  the  food 
not  washed  down  with  it.  For  these  various  reasons  many  prefer  tea 
to  coffee,  but,  used  in  large  quantities,  this  also  has  its  ills;  marked 
constipation  often  follows  its  excessive  use  from  the  excess  of  tannic 
acid,  for  in  the  homes  of  the  poor  and  the  kitchens  of  the  rich  for 
the  servants  the  teapot  stands  upon  the  stove  the  livelong  day,  fresh- 
ened only  by  the  addition  of  new  tea  leaves.  Tea  and  coffee,  both  in 
small  quantities,  as  a  tablespoonful,  form  an  admirable  adjuvant 
to  a  glass  of  milk  when  there  is  distaste  present,  and  undoubtedly  add 
to  its  digestion. 

Cocoa  and  chocolate  are  true  foods,  and  their  content  in  theobromine 
(or  the  "deadly  caffeine,"  as  Battle  Creek  would  call  it)  lies  between 
coffee,  which  has  less,  and  tea,  which  has  more.  Cocoa  cooked  with  half 
milk  and  half  water  has  no  inconsiderable  food  value.  For  instance,  its 
protein  is  3.5  per  cent,  its  fat  4  per  cent,  and  its  carbohydrate  5.2 
per  cent.  The  Holland  varieties  often  contain  potash,  soda,  or  mag- 
nesia, added  by  the  manufacturers  to  make  them  more  soluble,  and 
hence  are  not  to  be  recommended  to  those  with  digestive  disturbances. 


DIETETICS   IN   DIGESTIVE  DISORDERS  205 

On  account  of  their  large  content  in  fat  and  added  sugar,  these  pre- 
pared cocoas  often  cause  heartburn,  which  disadvantages  have  been 
somewhat  overcome  by  the  ' '  digestible ' '  cocoas  which  are  on  the  market 
and  which  can  generally  be  taken  by  the  possessors  of  the  weakest 
stomach.  A  rather  interesting  observation  has  been  made  by  Prager, 
that  the  addition  of  milk  to  cocoa  and  cream  to  coffee  delays  their 
departure  from  the  stomach  an  hour. 

Alcohol  has  been  a  bane  of  contention  for  many  years  as  to  its  nutri- 
tive value.  Thirty  years  ago,  in  pursuance  of  a  state  law,  it  was  the 
author's  duty  to  teach  the  use  of  alcohol,  but  after  a  short  period  the 
discovery  was  made  that  it  was  the  abuse,  and  not  the  use,  that  was  to 
be  taught,  for,  as  the  academy  trustees  gravely  stated,  "it  had  no 
use ' ' ;  yet  it  has  been  demonstrated  again  and  again  that,  through  its 
power  of  sparing  both  the  fat  and  protein  of  the  body  when  ingested, 
it  is  not  merely  a  beverage,  but  at  least  a  "near  food."  Still,  on 
account  of  its  toxic  properties,  when  its  use  exceeds  a  certain  limit,  it 
must  be  employed  with  great  caution.  The  healthy  adult  is  able  by 
the  possession  of  antidotal  powers  in  his  body  to  neutralize  partially 
these  toxic  effects,  much  as  is  done  with  the  products  of  autointoxica- 
tion, but  those  suffering  from  nervous  diseases,  especially  neuras- 
thenics, have  largely  lost  this  power.  The  effect  of  alcohol  on  the  di- 
gestion in  small  quantities  is  to  increase  both  secretion  and  motility — 
in  large  quantities,  to  paralyze  them;  hence  alcohol  should  not  be 
allowed  when  gastric  hypersecretion  is  present,  but  may  be  used  after 
the  meal  is  eaten  by  those  whose  gastric  motility  is  impaired.  ' '  Take  a 
little  wine  for  thy  stomach's  sake"  is  just  as  good  advice  now  as  two 
thousand  years  ago,  but  it  is  to  be  amended  by  interposing  post 
cenam.  The  vicious  habit  of  drinking  alcoholics  before  breakfast  and 
the  cocktail  before  a  meal  cannot  be  too  severely  reprehended.  The 
most  satisfactory  wines  are  those  freely  fermented — varieties  known 
as  Rhine  wines,  Niersteiner,  Hochheimer,  etc. — but  which  can  be  pro- 
duced equally  as  well  in  California ;  in  fact,  from  the  author 's  personal 
knowledge  much  wine  from  that  state  has  made  the  journey  to  Ger- 
many in  casks  to  return  to  this  country  in  flasks  as  imported  Rhine 
wines,  mixed,  of  course,  with  a  portion  of  the  real  article.  When  the 
wine  is  too  acid,  a  little  alkaline  water,  like  Vichy,  may  be  added,  as  is 
the  custom  in  Vienna.  When  wine  disagrees  and  produces  heart- 
burn, it  is  reasonable  to  assume  that  it  was  made  from  unripe  fruit, 
and  the  same  is  true  of  oranges,  lemons,  and  strawberries  when  they 
cause  heartburn,  for  ripe  fruit  juices  will  not  do  this.     Freshly  fer- 


206  DISEASES   OF    THE   DIGESTIVE   TRACT 

merited  new  wines  are  to  be  avoided,  and  this  is  the  very  reason  that 
California  wines  are  apt  to  disagree  in  that  they  are  marketed  before 
age  has  had  time  to  remove  the  substances  like  fusel  oil  and  yeast 
remnants,  which  have  a  toxic  action  on  the  nervous  system  and 
fermentative  action  on  the  foods  in  the  stomach.  To  what  extent  the 
various  "processes,"  widely  advertised,  are  supposed  to  free  the  new 
wine  from  these  deleterious  substances  is  difficult  to  say.  Special 
wines  have  won  great  renown  for  their  favorable  influence  on  certain 
diseases — ^like  elderberry  and  huckleberry  wines  for  diarrhea,  cider  and 
rhubarb  wines  for  constipation — and  undoubtedly  they  do  affect  such 
disorders  favorably.  Even  the  infusion  of  dried  huckleberry  has  a 
favorable  influence  on  intestinal  catarrh,  an  action  which  is  undoubt- 
edly due  to  its  tannic  acid  content.  Of  the  various  cocktails  and 
bitters  said  to  arouse  appetite  and  improve  digestion,  our  best  advice 
to  our  patients  is  to  let  them  alone  and  confine  themselves  to  a  liquor 
glass  of  good  brandy  or  whisky,  well  diluted,  after  the  meal,  for,  if 
taken  undiluted,  many  complain  of  the  burning  produced  by  it. 
Champagne  is  of  great  service  where  nausea  is  present  and  rapid  action 
is  desired,  because  the  carbon  dioxide  dulls  the  sensitiveness  of  the 
stomach  and  hastens  absorption.  It  is  unwise  to  give  it  to  invalids, 
however,  with  its  full  charge  of  carbon  dioxide,  a  portion  of  which 
should  be  allowed  to  escape,  nor  should  it  be  given  ice-cold. 

The  unfermented  sterilized  fruit  juices,  such  as  grape  juice  and 
orange,  are  admirably  adapted  to  produce  a  laxative  effect  on  the 
stool,  and  are  equally  as  well  suited  to  overcome  the  putrefaction  in 
the  colon  as  buttermilk,  which  has  found  so  many  earnest  advocates. 
Incidentally,  nothing  can  be  better  adapted  to  stimulate  the  secretion 
of  urine  than  these  fruit  juices.  We  must  assume,  however,  that  no 
antiseptic  is  used  in  their  preservation. 

Beer,  in  general,  should  be  forbidden  to  those  suffering  from  gastric 
disorders,  but  not  necessarily  from  intestinal,  for  the  following 
reasons :  it  is  usually  taken  in  fairly  large  quantities  on  account  of  its 
low  alcoholic  content,  thereby  overdistending  the  stomach,  generally 
affected  with  atony;  is  taken  ice  cold  and  is  very  liable  to  produce 
fermentation  in  the  stomach  from  the  yeast  fragments  or  their  ferment 
remaining,  but  recently  this  has  been  largely  overcome  by  sterilizing 
the  beer  before  it  is  marketed.  With  intestinal  putrefaction,  due  to  a 
sluggish  action  of  the  bowel,  however,  the  heavy  beers,  like  Wiirz- 
burger  or  Kulmbacher,  or  even  a  malt  extract  of  low  alcoholic  content, 
like  liquid  bread,  are  very  beneficial. 


DIETETICS   IN   DIGESTIVE  DISORDERS 


207 


CONTENT   OF    SOME   ALCOHOLIC   BEVERAGES. 


Percentage 
of  the 
diflferent 
ingredients. 


K 


C3 
60 

3 

H  c3 

H  C3 

Calori 
per  t! 
spoon 
(20   c 

0.85 

Vari- 

0.81 

12-15 

0.62 

able 

0.65 

12-15 

0.52 

2.12 
Vari- 

0.45 

26 
100 

able 

55 

0.88 

0.19 

10 
Glass,  120 

10 
Glass,  120 

10 
Glass,  120 

Rhine  Wine    8  2.6 

Elderberry  or  Huckleberry   .  .  8.55  2.87 

Sherry   17.45  3.98 

Brandy    69.5  0.65 

Whisky    36.5  0.25 

German  beer 3.93  5.79 

American   beer 4.45  5.92 

Malt    (liquid)    extract    3.94  5.13 


CONTENT   OF   SOME   LIQUID   FOODS   AND    CONDIMENTS. 


Percentage.  ^ 

Whole   milk    87.4 

Cream     65.5 

Condensed    milk    without 

sugar     53.5 

Buttermilk    90.2 

Koumiss      or      kefir      (2 

days)     91.0 

Beef  tea   97.5 

Cocoa    (2y2   teaspoonfuls 

to  half  cup  each  milk 

and  water    88.2 


rt 
^ 

6^ 

3.4 

3.6 

4.8 

3.6 

20-21 

3.52 

14.6 

14.0 

15.3 

4.0 

0.9 

3.7 

3.3 

2.2 

1.9 

0.3 

0.2 

1.25 

S        .2 


13-S 


0.35    0.53 


0.4 


3.6 


4.0       5.0 


160 
450 

Teaspoon,  70 

80 

113.5 
5-20 


181.1 


As  reference  has  been  made  to  calories,  by  which  measurement  we 
determine  whether  patients  are  receiving  nourishment  commensurate 
with  their  weight  and  state  (rest  or  activity),  it  would  perhaps  be 
well  to  briefly  state  the  method  of  determining  the  calorie  value  of 
food,  though  tables  are  now  prepared  like  interest  tables  which  give 
all  the  combinations.     For  instance,  an  individual  in  bed,  weighing 


208  DISEASES   OF    THE   DIGESTIVE   TRACT 

150  pounds,  requires  1,800  calories,  and  at  hard  work,  3,000.     Each 
gram  of  every  food  element  has  its  caloric  value,  as  follows : 

1  gram  protein     4.1  calories 

1  gram  carbohydrates     4.1  calories 

1  gram  fat     9.3  calories 

1  gram  alcohol     7.0  calories 

Hence  in  the  last  instance,  not  knowing  the  caloric  value  of  a  cup 
of  cocoa,  the  calculation  was  made  as  follows:  a  cup  (250  c.c),  with 
3.6  per  cent  protein,  contained  9  grams,  with  a  caloric  value  of  9  x  4.1 
or  36.9 ;  an  amount  of  fat  equal  to  250  x  .04  or  10,  with  a  calorie  value 
of  93 ;  a  carbohydrate  equal  to  250  x  .05  or  12.5,  with  a  caloric  value 
of  51.2,  or  a  total  caloric  value  of  181.1.  AYhen  we  stop  to  consider 
that  even  in  bed  a  moderate-sized  individual  must  drink  ten  cups  of 
cocoa  daily  to  obtain  the  required  1,800  calories,  or  2i/^  quarts,  we 
see  the  improvidence  of  attempting  to  nourish  with  liquid  food  alone, 
and  pass  to  the  next  division. 

SOLID  FOOD. 

Solid  food  is  undoubtedly  more  difficult  of  digestion  than  liquid, 
leaves  the  stomach  much  more  slowly,  and  is  more  difficult  of  absorp- 
tion than  the  latter.  It  also  demands  much  more  thorough  cooking 
and  better  mastication  than  the  latter,  especially  for  those  suffering, 
as  they  call  it,  from  ' '  stomach  trouble. ' ' 

Eggs  afford  the  most  concentrated  of  all  foods,  and  are  generally 
acceptable  to  all.  One  egg  weighing  from  II/2  to  2  ounces  is  equivalent 
to  1%  ounces  of  fat  meat  or  %  of  a  glass  of  milk.  AYhen  we  come 
to  consider  the  digestibility  of  eggs,  we  must  remember  that  they  form 
a  fatty  food,  the  fat  and  protein  content  being  nearly  alike  (5  and  6 
per  cent)  ;  hence  some  complain  of  being  made  "bilious"  by  them, 
probably  from  their  fat  content.  Therefore  great  care  must  be  taken 
in  the  method  of  cooking  for  weak  digestions,  many  complaining  that 
a  hard-boiled  egg  "lies  like  a  rock"  in  their  stomachs,  or  may  even 
produce  pain.  This  probably  depends  on  the  difficulty  of  liquefaction 
of  the  hard  lumps  of  egg  albumin,  which  irritate  a  sensitive  gastric 
mucous  membrane,  for,  when  one  has  reduced  these  fragments  to  a 
powder  by  a  grater,  their  ingestion  causes  no  difficulty.  Fried  eggs 
also  cause  delayed  and  uncomfortable  digestion  in  the  patient  and 
should  be  avoided ;  hence  the  best  methods  of  cooking  for  a  weak  diges- 
tion are  the  "soft-boiled"  or  "dropned"  egg,  in  which  the  albumin  is 


DIETETICS   IN   DIGESTIVE   DISORDERS  209 

brought  to  a  state  of  light  coagulation.  Scrambling  with  a  modicum  of 
butter,  or  beating  well  and  pouring  into  boiling  bouillon,  the  ' '  Suppe 
mit  Ei"  of  the  Germans,  are  also  suitable  methods  of  preparation.  Ke- 
cently,  unfortunately,  a  vicious  habit  has  sprung  up  of  breaking  large 
numbers  of  eggs — good,  bad,  and  indifferent — into  cans,  or  drying 
them,  and  employing  for  cooking.  Many  of  these  cans  contain 
ptomaine-like  bodies  from  decomposition,  and  ptomaine  poisoning 
from  ice  cream  and  mayonnaise  dressing  has  been  common.  The  gov- 
ernment has  stopped  the  importation  of  these  from  China,  and  the 
supply  from  the  Middle  West  coming  under  interstate  law  is  closely 
scrutinized  and  much  diminished.  For  the  methods  of  cooking  men- 
tioned and  to  take  raw  with  milk,  only  the  freshest  eggs  should  be  em- 
ployed, and  it  is  with  alarm  we  view  the  fact  that  the  price  of  such 
has  soared  above  the  means  of  a  laboring  man,  for  it  is  often  his  im- 
properly nourished  children  who  need  them  most.  It  is  amusing  to 
note  the  efforts  of  the  pharmacists  to  establish  a  sale  for  lecithin,  with 
its  valuable  glycerophosphoric  acid,  when  the  yolk  of  every  egg  con- 
tains it  in  generous  quantities.  For  those  who  can  afford  it,  the 
Russian  caviar,  with  its  30  per  cent  of  protein  and  15  per  cent  fat, 
serves  the  same  end  as  eggs,  and  as  an  appetizer  before  a  meal  it  far 
surpasses  the  cocktail  and  is  less  harmful. 

Meat,  as  far  as  digestibility  is  concerned,  is  judged  by  its  amount 
of  fat,  for  the  more  of  this  there  is  the  more  difficult  it  is  for  the 
gastric  juice  to  penetrate  the  albumin  and  the  longer  it  takes  to  leave 
the  stomach.  Based  on  this  criterion,  we  find  the  white  iheat  of  fowl,' 
veal,  and  sweet-breads  to  be  the  most  digestible.  All  of  these  meats, 
too,  have  a  softer  consistency,  a  quality  which  calves '  brain  shares,  but 
contains  a  large  amount  of  fat  and  is  less  adapted.  When  it  comes 
to  extractives,  as  Senator  remarks,  we  must  give  our  attention  not 
only  to  the  nitrogen-containing,  but  the  nitrogen-free  variety,  and, 
while  the  former  differs  but  little  in  light  and  dark  meats,  there  is  a 
marked  difference  in  the  latter.  For  instance,  beef  has  0.46  per  cent 
nitrogen  free  extractives  when  raw,  and  0.76  per  cent  when  cooked, 
while  veal  under  like  conditions  has  respectively  0.07  per  cent  and 
0.4  per  cent.  As  far  as  raw  meat  is  concerned,  if  it  is  well  chopped 
and  the  coarser  tendons  removed,  with  a  normal  gastric  juice,  com- 
plete utilization  takes  place  in  the  intestine,  but  attention  has  already 
been  called  to  the  former  frequency  of  its  use  by  physician's  orders  in 
children  and  the  increased  prevalence  of  tapeworm.  This  might  not 
happen  again  on  account  of  more  careful  inspection  of  meats  by  the 
United  States  authorities,  but  one  feels  safer  when  meat  is  cooked. 


210  DISEASES   OF   THE   DIGESTIVE   TRACT 

A  table  of  periods  at  which  the  stomach  is  free  from  meat  remnants 
after  a  meal  varies  from  two  hours  and  twenty-five  minutes  for  boiled 
calves'  brain  to  five  hours  and  twenty-five  minutes  for  roast  mutton, 
all  periods  being  pretty  closely  allied  with  the  fat  content  of  the  meat. 
Thus  arranged  according  to  fat  content  and  digestibility,  we  would 
have : 

Fat. 

Sweetbreads,  veal,  pike,  oj'sters,  and  haddock 0.4 — 1  per  cent. 

Beef,  hare,  chicken,  squab,  and  partridge :  1    — 1.5  per  cent. 

Mutton  and  pork   5    — 7  per  cent. 

Goose,  caviar,  herring,  salmon,  eel,  and  mackerel   ....  over  8  per  cent. 

In  general,  it  may  be  said  that  rare  meat  is  better  digested  than 
thoroughly  cooked,  but  the  meat  must  first  be  hung  up  for  a  long  time 
to  ripen,  which  softens  the  connective  tissue  by  the  action  of  post- 
mortal formed  lactic  acid,  while  the  myosin  coagulation  is  softened 
by  the  action  of  a  growth  of  harmless  bacteria.  Still,  this  process  of 
ripening  should  not  be  allowed  to  continue  too  long,  for  the  smallest 
amount  of  deleterious  substances  produced  by  putrefaction  may  harm 
a  weak  digestion.  Very  often  roasted  meats  are  best  eaten  cold,  and  a 
sandwich  made  with  stale  bread  and  cold  roasted  meat  makes  a  food 
well  taken  care  of  by  the  weakest  stomach,  either  as  part  of  the  chief 
meals  or  as  an  adjuvant  meal  at  11  a.  m,  and  4  p.  m.  Another  excel- 
lent form  of  employing  meat  is  in  the  use  of  Hamburger  steak,  or,  what 
is  better,  meat  cut  at  home  by  a  meat  cutter,  for  a  better  selection  can 
be  made  at  the  market.  Meats  prepared  in  this  way  can  be  steamed 
or  baked,  and  not  fried,  as  is  unfortunately  often  the  custom.  In 
the  restaurants  we  can  usually  obtain  them  as  minced  chicken,  lamb, 
fish,  etc.,  on  toast,  or  as  the  much  maligned  hash,  which,  properly  pre- 
pared, is  a  food  par  excellence,  and  throws  the  least  burden  on  the 
digestion  on  account  of  the  minute  division.  Fowl  is  much  more 
readily  digested  when  boiled  or  fricasseed  than  when  roasted.  Of  game, 
venison  and  hare  are  to  be  given  the  preference  on  account  of  the  lack 
of  fat,  though  the  fiber  is  coarser  than  that  of  beef,  but  by  appropriate 
cooking  this  disadvantage  can  be  somewhat  overcome.  The  age  of  the 
animal  has  also  something  to  do  with  the  digestibility  of  the  meat,  and 
that  of  young  animals  should  always  be  chosen  for  invalids  because 
more  tender. 

Preserved  meats — tongue,  ham,  corn  beef,  and  dried  beef — should 
not  be  used  by  dyspeptics  except  in  emergencies,  and  then  in  small 
quantities,  since  they  always  retard  the  gastric  digestion  and  are  poorly 
utilized.     Canned  beef  loses  its  extractives  and  phosphoric  acid  largely 


DIETETICS   IN   DIGESTIVE   DISORDERS  211 

by  the  process  of  curing,  thus  decreasing  its  palatability,  as  the  round 
robin  of  the  Spanish- American  soldiers  in  regard  to  the  ''embalmed" 
beef  showed.  Ham  should  be  lightly  smoked  or  "sugar  cured,"  and 
should  never  be  eaten  raw  for  fear  of  triehinaB,  though  more  digestible ; 
ox  tongue  contains  much  fat,  and  the  tip  a  very  coarse  fiber;  sausage 
should  be  avoided  on  account  of  its  excess  of  fat  and  numerous  spices, 
but  the  interior  of  Frankfurters,  on  account  of  its  finely  divided  state, 
has  proved  satisfactory  to  the  author  with  patients  possessing  atonic 
stomachs. 

Fish,  on  account  of  its  large  water  content,  is  often  regarded  as  less 
nutritive  than  meat,  but  erroneously  so,  for  it  contains  a  large  amount 
of  albumin  and  substance  yielding  gelatine.  One  of  At  water's  serv- 
ices to  dietetics  was  to  show  that  1,500  grams  of  haddock  was  equal 
to  1,200  grams  of  beef  in  actual  nutrient  value,  so  that  fish  can  be 
compared  favorably  with  veal  in  that  respect.  The  lean  varieties — 
like  haddock,  trout,  perch,  pickerel,  and  sole — are  to  be  regarded  as 
easily  digested  and  allowed,  while  the  fatter  kinds — sword  fish,  mack- 
erel, halibut,  and  salmon — are  to  be  forbidden.  As  to  the  digestibility 
of  oysters,  opinions  differ,  but  raw,  with  lemon  juice,  if  their  source 
is  unquestioned  (typhoid),  they  have  served  the  author  admirably; 
panned  or  cooked  in  their  own  juice,  they  are  equally  digestible ;  but 
as  a  stew,  cooked  with  milk  and  butter,  they  often  cause  gastric  dis- 
tress. 

Bouillon  and  beef  tea  both  lost  their  renown  as  foods  when  we  began 
to  actually  calculate  their  nutritive  values,  which  are:  protein,  0.3-1.8 
per  cent ;  or  from  veal  possibly  as  high  as  2.8  per  cent ;  and  fat,  0,2- 
0.4  per  cent.  Of  extractives,  however,  the  percentage  may  rise  to 
3.6  per  cent,  and  in  this  lies  their  value  in  that  they  arouse  appetite 
and  the  flow  of  gastric  juice.  Tell  any  patient  who  complains  of  loss 
of  appetite  in  the  morning  and  the  sense  of  not  having  rested,  to 
begin  the  day,  if  possible,  or  even  before  retiring,  with  a  cup  of  beef 
tea,  and  note  his  satisfaction  with  this  method  of  arousing  the  ap- 
petite. On  account  of  its  power  to  excite  and  increase  gastric  secre- 
tion, it  should  never  be  used  when  there  is  an  excessive  flow  of  gastric 
juice,  and  from  the  fact  that  these  meat  extractives  contain  large  uric 
acid  producing  residues  and  usually  raise  blood  pressure,  bouillon 
should  not  be  given  to  the  gouty  or  to  those  with  impaired  arteries. 
Whether  soup  should  be  taken  before  the  main  meal,  as  is  the  custom, 
depends,  of  course,  on  the  gastric  motility  of  the  patient.  "When  that 
is  impaired,  he  should  certainly  refrain,  because  the  percentage  of 
nutriment  is  so  low  that  there  is  not  adequate  return  for  the  extra 


212  DISEASES  OF   THE   DIGESTIVE   TRACT 

burden  the  stomach  has  to  bear.  With  bouillon  and  beef  tea  are  to 
be  reckoned  the  regular  beef  extracts,  like  liquid  beef,  which  is  the 
cold  pressed  juice  of  fresh  meat  preserved  in  some  way,  and  the  vari- 
ous raw  and  cooked  blood  preparations  on  the  market.  Their  analyses 
as  sold  sound  attractive,  but,  when  diluted  as  directed  and  the  re- 
sulting product  analyzed,  we  find  we  are  in  the  realm  of  attenuations 
so  praised  by  one  of  our  schools  of  medicine.  In  justice  to  many  of 
these  preparations,  it  should  be  stated  that  the  protein  is  partially 
digested,  which  makes  them  more  acceptable  to  an  impaired  stom- 
ach. 

The  predigested  albumin,  either  of  animal  or  vegetable  origin,  or  a 
mixture  of  both,  either  as  powder  or  liquid,  is  found  on  the  market 
in  the  form  of  a  number  of  preparations,  and  has  a  limited  value  (1) 
as  addition  to  liquid  food  (milk  or  bouillon)  to  increase  its  caloric 
value  in  fevers,  wasting  diseases,  and  in  building  up  the  patient  after 
acute  diseases  or  operations;  (2)  in  arousing  appetite  with  diminished 
gastric  secretion  (anemia,  neurasthenia,  etc.)  ;  (3)  where  both  secre- 
tion and  motility  are  impaired;  (4)  where,  as  sometimes  happens, 
nourishment  must  be  given  through  a  tube  or  by  rectum.  Of  all  these 
predigested  meat  preparations  it  may  be  said  that,  when  used  to  a 
large  extent,  they  produce  diarrhea  and  appear  in  the  urine,  though 
merely  as  an  adjuvant  to  other  foods  they  rarely  do  this;  and  also 
that,  considering  their  actual  food  value,  the  price  appears  exorbitant. 
As  all  of  these  preparations  have  their  adherents,  and  enthusiastic 
testimonial  writers  have  expressed  their  encomiums  on  them,  it  is  the 
author's  duty  to  refrain  from  naming  them  other  than  as  a  group, 
only  remarking  that  they  can  be  recognized  on  the  label  by  the  word 
''predigested,"  which  is  supposed  to  convey  some  magic  charm. 

Casein  and  its  modifications  form  another  group  of  ready-made,  if 
not  readily  digested,  foods,  which  is  chiefly  distinguished  from  the 
former  by  its  lesser  price.  Modified  by  the  addition  of  some  alkali 
to  satisfy  its  acid  properties,  this  class  of  prepared  foods  seems  to  be 
better  utilized  than  the  group  from  meat  (93.3  per  cent  of  the  former, 
82.7  per  cent  of  the  latter).  Then,  starting  from  casein  as  a  basis, 
all  imaginary  combinations  have  been  devised  until  we  have  reached 
in  the  newest  effort  a  casein-iron-lecithin  compound. 

Vegetable  protein,  gluten,  has  also  been  called  on  to  furnish  a  new 
nerve  food,  at  least  two  varieties  of  which  are  on  the  market.  At 
first  the  taste  of  these  preparations  left  much  to  be  desired,  but  re- 
cently it  has  been  so  much  improved  that  no  complaint  is  made  by 
patients  in  that  regard.     This  group,  too,  is  favored  by  the  low  cost 


DIETETICS  IN   DIGESTIVE  DISORDERS  213 

and  freedom  from  starch,  which  latter  factor  allows  it  to  be  used 
by  diabetics. 

Gelatine-containing  food  preparations  all  come  from  gristle,  tendons, 
connective  tissue,  and  bone.  Apart  from  the  French  gelatine,  it  is 
put  up  in  attractive  packages,  often  flavored  with  fruit  juices,  and 
requires  only  the  addition  of  boiling  water,  when  it  can  be  molded 
into  attractive  forms  and  served  with  cream  and  sugar.  This  gelatine 
has  been  found  to  be  wholly  absorbed  in  the  intestines,  and,  on  ac- 
count of  its  rapid  assimilation  in  the  tissues  of  the  body,  has  proven 
to  be  a  sparer  of  both  protein  and  fat,  thus  proving  an  admirable  aid 
to  the  nitrogen  increase  of  the  body.  More  recent  investigations  show 
that  it  can  replace  body  protein  only  to  the  extent  of  61  per  cent, 
but  in  small  quantities  emphatically  prevents  its  loss.  Gelatine  can- 
not be  employed  beyond  a  limited  extent,  else  it  produces  irritation 
of  the  intestine  and  diarrhea.  Furthermore,  gelatine  has  been  found 
to  combat  the  tendency  to  hemorrhage,  not  only  when  injected  sub- 
cutaneously,  which,  unfortunately,  has  sometimes  produced  tetanus, 
but  also  when  given  by  the  mouth  or  rectal  injection,  though  less 
rapidly,  and  has  proven  very  valuable  in  melena  neonatorum  and 
slowly  bleeding  gastric  ulcer. 

Fat,  too,  forms  a  very  important  part  of  our  nourishment,  since, 
like  gelatine,  it  is  also  a  protein  sparer  to  the  extent  of  7-15  per  cent. 
Recently,  as  mentioned,  a  part  of  the  fat  digestion  has  been  found  to 
take  place  in  the  stomach,  either  from  an  inherent  ferment,  or,  more 
probably,  from  the  reflux  of  duodenal  contents  through  the  pylorus, 
but  the  greater  part  must  take  place  in  the  intestine,  and  demands  the 
normal  secretion  of  the  liver  and  pancreas  as  well  as  their  free  dis- 
charge into  the  tract.  The  use  of  fat  as  food  undoubtedly  lessens 
gastric  hypersecretion,  and  probably  does  not  retard  motility  as  much 
as  has  been  formerly  supposed;  at  least  H.  Strauss  and  B.  Cohnheim 
have  claimed  a  very  beneficial  effect  of  abundant  fat  ingestion  in  dis- 
turbances of  gastric  motility.  It  has  also  been  found  that,  in  marked 
disturbances  of  the  intestinal  functions  accompanied  by  diarrhea,  fat 
is  often  well  borne,  well  utilized,  and  exerts  a  powerful  influence 
in  staying  the  failing  strength  of  the  patient.  The  fats  most  com- 
monly used  and  most  easily  digested  are  butter,  olive  oil,  and  oleomar- 
garine; the  last — though  various  parties  producing  real  butter  have 
demanded  and  in  some  states  secured  by  law  that  it  shall  be  colored 
pink,  etc.,  ostensibly  to  prevent  deception,  but  really  to  produce  dis- 
taste for  it — is  really  a  very  nutritious  and  harmless  preparation, 
though  not  equal  in  food  value,  pound  for  pound,  with  true  butter, 


214  DISEASES   OF   THE   DIGESTIVE   TRACT 

since  some  of  its  fats  are  of  a  higher  melting  point  and  hence  less  well 
utilized.  Still,  with  true  butter  at  the  exorbitant  prices  of  the  last 
few  years,  oleomargarine  has  proved  a  blessing  to  the  man  of  limited 
means,  and,  if  distinctly  labeled,  so  that  the  purchaser  may  know 
that  he  is  buying  an  inferior  but  no  less  healthful  food,  just  as  when 
he  buys  an  inferior  coal,  no  harm  can  be  done.  Cocoanut  butter  and 
cotton-seed  oil,  most  common  in  the  form  of  eottoline,  are  now  used 
largely  for  cooking  as  substitutes  for  lard,  whose  price  has  also  soared, 
and  apparently  with  relief  to  the  individual's  purse  and  no  harm  to 
the  patient's  health.  One  of  the  very  best  methods  of  administer- 
ing fat  is  by  the  use  of  cream,  because  it  can  be  better  regulated,  and 
often  the  author's  advice  to  patients  is  to  buy  a  half  pint  of  thin 
cream  (20  per  cent)  daily,  and  take  the  same  salted  on  baked  potato, 
sweetened  on  stale  bread,  and  richly  in  tea,  coffee,  cocoa,  or  even  to 
enrich  the  milk,  but  never  to  drink  undiluted,  for  the  best  stomach 
will  often  rebel  at  the  excess  of  fat.  Olive  oil,  if  good,  which  is  rarely 
true  of  the  variety  found  in  our  best  restaurants,  can  be  taken  freely 
on  almost  any  cold  boiled  vegetable,  or  on  lettuce,  water-cress,  etc., 
perhaps  with  some  lemon  juice  for  a  flavor,  or  a  wineglass  of  the  pure 
oil  taken  night  and  morning,  which,  especially  if  cooled  in  a  re- 
frigerator, may  be  swallowed  without  any  difficulty,  thereby  sooth- 
ing the  irritated  mucous  membrane  of  the  stomach,  reducing  its 
secretion,  and  often  producing  a  daily  stool,  provided  that  gastric 
motility  is  not  impaired. 

Cheese,  though  extremely  nutritious,  containing,  according  to  the 
variety,  24—32  per  cent  of  albumin  and  4-30  per  cent  of  fat,  is  not  so 
readily  digested  on  account  of  this  very  fat  content.  In  one  of  the 
author's  earliest  medical  works  this  distich  was  found: 

"Cheese  is  a   surly  elf, 
Digesting  all  things  save  itself." 

In  a  rather  wide  experience,  not  only  has  this  proven  true,  but, 
what  makes  it  still  more  emphatic,  is  firmly  grounded  in  the  minds 
of  the  laity.  Still,  in  the  author's  practice  use  is  often  made  of 
Neuchatel,  with  good  results,  and  AVegele  recommends  highly  the 
Parmesan  cheese,  well  grated,  as  it  is  usually  served,  on  account  of  its 
lessened  fat  content.  Salkowski,  too,  recommends  the  use  of  casein 
in  place  of  the  peptone  preparations,  and  Rubner  has  found  that  cheese 
added  to  milk,  or  taken  in  conjunction  with  milk,  increases  the  utiliza- 
tion of  the  latter  by  producing  a  finer  curd.  Late  investigations  have 
shown  that  Roquefort  and  Chester  cheese  remain  the  shortest  time 


Albumin. 

Fat. 

Carbo- 
hydrates. 

0.71 

83.27 

0.58 

0.1 

85.8 

0.12 

98.10 

25.09 

29.05 

2.22 

34.99 

11.37 

5.40 

DIETETICS   IN   DIGESTIVE   DISORDERS  215 

in  the  stomach,  but  their  use  cannot  be  recommended  for  dyspeptics 
on  account  of  the  addition  of  condiments  and  their  stimulating  bac- 
terial products.  Various  preparations  have  been  employed  to  increase 
the  fat  content  of  the  diet,  most  of  which  rest  on  codliver  oil  and  egg 
yolk  as  a  basis,  and  are  "flavored  to  taste,"  as  the  cook-books  read. 
We  are  now  skeptical  in  regard  to  any  therapeutic  value  which  cod- 
liver  oil  may  have  other  than  dietetic,  but  it  does  seem  often  the  real 
adjuvant  needed  to  regulated  diet  to  put  our  patients  on  a  weight  in- 
crease. Unfortunately  many  complain  of  eructations  after  its  use, 
and  possibly,  if  some  of  the  fat  existed  as  fatty  acids,  like  the  German 
lipanin,  this  might  be  overcome. 

COMPOSITION    OF   FAT   RICH   FOODS. 
Water. 

Butter    14.49 

Oleomargarine    10.5 

Lard     0.71 

Fatty   cheese    39.09 

Fat  poor   cheese    43.87 

Chester  cheese   33.96  27.68  27.46  5.89 

The  carbohydrate-containing  foods  continue  their  digestion,  as 
noted,  during  their  stay  in  the  stomach,  thanks  to  the  ptyalin,  until 
the  secretion  of  hydrochloric  acid  has  reached  a  point  where  the  proc- 
ess is  interrupted,  and  even  then  the  interruption  may  occur  only 
on  the  periphery  of  the  food  mass  in  the  stomach.  Although  the  en- 
trance of  the  acid  gastric  contents  into  the  intestine  produces  a  free 
flow  of  pancreatic  juice,  a  too  acid  content  hinders  very  much  the 
duodenal  digestion ;  but,  even  when  neither  bile  nor  pancreatic  juice 
can  make  its  way  into  the  intestine,  digestion  of  starch  goes  on,  and 
often  its  utilization  is  complete.  The  investigations  of  many  have 
shown  that  the  ingestion  of  carbohydrate  food  tends  to  inhibit  al- 
buminous putrefaction ;  in  fact,  no  evidence  of  the  latter  can  be  found 
on  a  purely  vegetable  diet.  This  is  of  particular  import  in  achylia 
gastriea  where  the  intestinal  disturbances  have  been  brought  on  by 
the  use  of  meat.  Still,  the  time  has  passed  when  man  can  economically 
sustain  himself  on  a  purely  vegetable  diet,  for,  though  his  nitrogen 
equilibrium  can  be  maintained,  he  must  devour  such  enormous  quan- 
tities of  material  to  keep  himself  in  normal  condition  that  the  diges- 
tion suffers.  The  Scotchman  has  a  powerful  physique,  not  on  account 
of  oatmeal,  but  his  vigorous  body  has  enabled  him  to  live  on  oatmeal. 
When,  however,  to  a  vegetarian  regimen  we  add  milk,  eggs,  cheese, 


216  DISEASES   OF   THE   DIGESTIVE   TRACT 

and  butter,  we  often  have  the  ideal  diet  for  nervous  dyspepsia,  even 
when  there  is  a  tendency  to  flatulency  and  autointoxication.  It  often 
happens  that  when  dealing  with  anemic  patients  we  often  wish  to 
select  a  suitable  diet  which  shall  be  rich  in  iron,  and  the  following 
brief  table  will  give  some  knowledge  of  the  comparative  amounts  of 
the  same: 

Percent. 

Potato     0.247  ferrous  o.xide 

Carrots     0.056  ferrous  oxide 

Lentils : 0.041  ferrous  oxide 

Apples  and   pears 0.02     ferrous  oxijde 

Strawberries    0.009  ferrous  oxide 

Spinach     0.002  ferrous  oxide 

The  cellulose  of  young  vegetables  is  largely  digested  bj'  the  saliva 
and  pancreatic  juice,  but  mostly  by  the  intestinal  bacteria.  Espe- 
cially is  this  true  of  spinach,  asparagus,  and  carrots,  where  the  utiliza- 
tion of  cellulose  amounts  to  47-63  per  cent.  In  this  process  marsh 
gas  and  organic  acids — carbon  dioxide,  acetic  and  butyric — are  formed, 
which  are  subsequently  fully  oxidized  and  utilized,  thereby  becoming 
fat  and  protein  sparers.  For  the  nourishment  of  those  with  diseased 
digestive  organs,  particularly  with  stenosis,  it  is  much  better  to  choose 
those  vegetable  foods  which  contain  but  a  small  percentage  of  cellulose. 

The  cereals,  which  are  used  largely  by  humans  for  food,  consist 
chiefly  of  wheat,  rye,  barley,  oats,  rice,  and  corn.  In  recent  years, 
however,  much  to  the  disadvantage  of  the  human  race,  wheat,  and 
particularly  the  white  finely  bolted  flour  made  from  it.  has  become 
the  staple  of  life,  to  the  neglect  of  the  others,  which  perhaps  pose  as 
ingredients  of  the  various  breakfast  foods  whose  identity  is  difficult 
to  trace  on  account  of  the  diverse  mechanical  processes  whick  they 
have  undergone,  like  "puffing,"  '^ cracking,"  ''toasting,"  etc.  All 
of  these  grains,  with  the  exception  of  hulled  corn  and  rice,  are  eaten 
after  grinding,  by  which  the  hull  of  cellulose  is  usually  removed, 
thereby  doing  away  with  the  whip  of  the  intestine.  From  the  wheat 
we  have  the  white  bread,  almost  universally  used  by  us ;  and  from  the 
rye  the  black  bread,  used  largely  by  foreigners ;  and  from  corn,  brown 
bread  and  corn  cakes,  used  by  our  forefathers  who  conquered  the  land, 
but  only  a  memory  to  those  of  the  present  day.  To  those  who  suffer 
from  gastric  fermentation,  the  black  bread  is  unsuited,  because,  made 
from  sour  dough,  it  encourages  such  processes;  this,  however,  in  the 
author's  experience  can  be  largely  overcome  by  toasting  the  rye  bread 
before  it  is  eaten.     The  white  bread  prepared  with  yeast  exhibits  in 


DIETETICS   IN   DIGESTIVE   DISORDERS  217 

a  much  less  degree  this  tendency  to  fermentation  after  it  is  eaten,  while 
the  Hosford  and  other  baking  powders  of  allied  nature  (usually  com- 
posed of  sodium  bicarbonate  or  saleratus,  and  either  potash  bitartrate 
or  cream  of  tartar,  aluminum  sulphate  or  alum,  or  acid  calcium  phos- 
phate) have  made  fortunes  for  many  manufacturers,  and  incidentally, 
in  the  form  of  hot  biscuits,  a  race  of  dyspeptics.  The  crust,  on  ac- 
count of  the  partial  conversion  of  its  starch  to  dextrins  by  the  heat,  is 
more  digestible  than  the  soft  inner  part  of  a  loaf,  an  advantage  which 
accrues  to  the  w^hole  loaf  by  slicing  and  toasting,  or  used  in  the  form 
of  zwieback.  Fresh  bread  has  long  possessed  in  the  minds  of  the 
laity  the  quality  of  being  more  indigestible  than  stale  bread,  but  in 
all  probability  this  apparent  disadvantage  is  only  one  of  greater  dif- 
ficulty of  thorough  mastication,  without  which  the  digestive  juices 
cannot  so  thoroughly  mix  with  it.  When  fresh  bread  is  carefully 
masticated,  it  does  not  suffer  in  digestibility  in  comparison  with  the 
stale  variety.  The  harder  varieties  of  bread,  like  rolls  and  toast,  must 
also  be  softened,  as  in  the  form  of  milk  or  cream  toast,  or  else  an 
equal  amount  of  care  must  be  taken  to  masticate  them,  for  it  is  no 
uncommon  thing  to  find  in  the  gastric  contents,  after  the  Ewald 
breakfast,  fragments  of  the  crust,  readily  recognized  by  its  color, 
which  are  entirely  unattacked  by  the  gastric  juice,  while  the  softer 
portions  are  finely  divided.  Graham  bread  or  whole  wheat  bread, 
w^hich  contains  the  ground  hulls  of  the  grain,  demands  a  normal 
digestive  juice  at  least  for  their  employment,  but  are  very  efficacious 
in  stimulating  intestinal  peristalsis.  Cereals  can  also  be  advanta- 
geously employed  in  soups,  either  as  flour  thickening  or  by  the  addition 
of  the  grains — rice,  barley,  etc. — whose  starch  is  largely  converted  to 
dextrin  by  boiling.  Too  much  dependence  should  not  be  placed  on 
its  caloric  value,  however,  for  such  soups  have  been  found  to  contain 
90  per  cent  water,  1  per  cent  albumin,  1.5  per  cent  fat^  and  5-6  per 
cent  carbohydrate;  very  rarely  does  the  latter  constituent  reach  10 
per  cent.  Especially  those  soups  in  which  the  cooked  grain  has  been 
rubbed  through  a  sieve  before  it  is  eaten,  or  to  w^hich  the  ground 
meal  is  added,  have  won  great  renown  since  Hippocrates  first  recom- 
mended them — known  to  him  as  "ptisans,"  to  us  as  broths.  Barley, 
oats,  and  tapioca  make  a  particularly  slimy  or  mucilaginous  mixture, 
which  are  supposed  to  act  as  a  soothing  application  to  the  digestive 
mucous  membrane,  but  probably  are  valuable  only  by  their  ready 
digestibility.  Gruels,  containing  much  the  same  constituents,  but  pre- 
pared with  milk,  have  also  had  a  wide  use  in  the  feeding  of  the  sick. 
According  to  Leube,  soups  containing  the  whole  grain  (barley,  rice. 


218  DISEASES   OF   THE   DIGESTIVE   TRACT 

oatmeal,  sago)  incite  in  a  marked  degree  secretion  of  gastric  juice, 
and ,  are  very  valuable  where  such  an  effect  is  desired.  The  use  of 
breakfast  foods,  so  common  with  us  that  every  restaurant  must  keep 
on  hand  a  dozen  varieties,  can  be  and  is  often  carried  to  excess,  for 
the  hulls,  particularly  of  oatmeal,  are  difficult  to  dissolve  and  must 
produce  some  irritation.  Perhaps  it  is  better  to  keep  these  in  reserve 
for  the  same  purpose  that  we  use  Graham  and  whole  wheat  bread — 
namely,  to  stimulate  peristalsis  in  an  atonic  colon.  In  the  author's 
estimation  it  would  be  much  more  desirable  to  make  a  more  com- 
mon use  of  rice,  either  in  soup,  as  a  breakfast  dish,  or  as  a  vegetable, 
so  common  in  the  South.  The  Japanese  have  developed  a  very  sturdy 
race  on  rice  and  fish,  and  it  is  a  misfortune  of  our  country  that  so 
much  rice  is  exported  and  so  little  eaten  at  home.  Rice  must,  however, 
be  so  thoroughly  cooked  that  the  grains  will  almost  fall  apart,  and 
perhaps  its  improper  cooking  may  have  retarded  its  popularity.  Rice 
and  Indian  corn  meal,  too,  can  be  made  into  very  palatable  and  nutri- 
tive puddings,  but  many  of  the  later  ventures  of  cooks  with  the  glory 
of  New  England,  an  Indian  meal  pudding,  have  been  dismal  failures, 
if  one  can  judge  from  what  is  presented  to  the  patron  of  our  best 
hotels  and  restaurants. 

The  leguminous  vegetables — pease,  beans,  etc. — are  particularly 
noted  for  their  large  protein  content  (25  per  cent),  and  also  their 
excess  of  carbohydrate  (50  per  cent),  and  hence  should  be  the  ideal 
food,  particularly  for  the  poorer  classes  because  inexpensive,  com- 
pared with  an  equal  amount  of  protein  and  starch  in  other  forms, 
provided,  of  course,  that  long  continued  cooking  has  rendered  their 
elements  available.  The  modem  method  of  treating  these  legumins 
like  wheat  by  conversion  to  pea  or  bean  flour,  or  split  pease,  has 
brought  them  into  the  dietary  of  the  sick,  and  a  soup  made  of  these 
prepared  legumins  is  well  borne  by  the  weakest  stomach.  So  great 
a  difference  exists  in  the  absorption  of  these  two  forms  that  Striimpell 
has  found  that  91.8  per  cent  of  the  protein  of  the  ground  variety  is 
utilized,  while  only  59,8  per  cent  of  the  whole  vegetable  is  available. 
The  New  England  baked  beans  have  won  a  reputation  for  indigesti- 
bility,  but  it  is  often  found  that  the  difficulty  is  caused  by  the  large 
amount  of  fat  (pork)  used,  and  that  beans  baked  with  mutton  or  but- 
ter may  be  eaten  without  producing  any  ill  effects. 

The  root  vegetables,  or  those  growing  underground,  have  by  no 
means  the  high  food  value  of  the  former.  Their  comparative  values 
lie  between  15-90  per  cent  water,  1-2  per  cent  protein,  and  8-20  per 
cent  carbohydrate,  with  the  exception  of  sago  and  tapioca,  which  have 


DIETETICS   IN   DIGESTIVE   DISORDERS  219 

85  per  cent  of  the  last.  Probably  the  most  extensively  used  and 
best  liked  of  this  group  is  the  potato,  which,  according  to  Kubner, 
does  not  deserve  this  extensive  use,  but  is  rather  only  a  "near  food." 
Either  baked  or  mashed,  this  vegetable  nevertheless  affords  a  ready 
means  of  obtaining  one  element  of  our  ration — carbohydrate — of 
which  the  ordinary  individual  must  have  500  grams  daily  in  an  inex- 
pensive and  thoroughly  economical  form,  for,  even  when  feces  show 
marked  waste  of  meat  and  fat,  rarely  does  one  find  any  excess  of  starch. 
Prepared  in  these  w^ays,  too,  the  weakest  digestion  can  usually  dispose 
of  its  portion  wdthout  discomfort.  When,  however,  a  race  attempts 
to  sustain  life  on  the  potato  alone,  as  did  the  Irish  at  one  time,  the  re- 
sult is  disastrous,  as  shown  by  the  ravages  of  tuberculosis  among  this 
people.  Turnips,  beets,  and  radishes  are  much  less  available  for  the 
weak  digestion,  and  have  decidedly  less  nutritive  value  because  of 
their  excess  of  cellulose,  but  may  be  used  to  advantage  in  combating 
intestinal  torpor.  For  their  nutritive  value,  too,  we  may  use  the 
young  beet  and  the  small  white  turnip,  which,  if  it  does  not  contain 
too  much  of  its  characteristic  oil — i.e.,  is  not  too  "strong" — can  be 
made  very  palatable,  but  should  always  be  eaten  mashed.  Carrots 
and  parsnips,  too,  particularly  w^hen  the  latter  has  been  allowed  to 
remain  in  the  frozen  ground  through  the  winter,  by  which  it  becomes 
very  tender,  form  a  very  palatable  and  easily  digested  group  of  veg- 
etables, but  are  not  to  be  compared  in  utilization  with  mashed  potato, 
squash,  or  young  white  turnips.  Sago  and  tapioca,  made  respectively 
from  the  pith  and  roots  of  shrubs,  by  their  process  of  isolation  are 
made  very  soluble  and  digestible,  but  must  not  be  depended  on  for 
nutrition  on  account  of  their  meager  protein  content.  Taken  in  soup, 
where  the  fat  and  protein  are  furnished  by  meat  or  egg,  or  as  a 
dessert  in  the  form  of  pudding  and  accessory  to  a  meat  course,  they 
form  a  valuable  adjuvant  because  so  readily  digested  and  completely 
utilized.  The  green  vegetables — ^lettuce,  spinach,  water-cress,  and 
the  cabbage  family,  cabbage,  cauliflower  and  Brussels  sprouts — had 
best  be  stricken  from  the  dietary  of  the  dyspeptic  because  they  contain 
so  much  cellulose  and  so  little  nutriment,  and  the  latter  particularly 
produce  much  gas.  Sourkrout,  in  the  author's  experience,  has  in  a 
much  less  degree  these  disagreeable  effects,  and,  cooked  with  sausage 
or  meat,  retains  enough  fat  to  make  it  contain  a  moderate  amount  of 
nutriment.  All  these  vegetables  have  a  distinct  use  in  acting  as  a 
whip  to  the  intestine  when  sluggish,  in  serving  as  a  vehicle  for  fat, 
and  convincing  the  diabetic  patient  that  he  is  really  eating  something, 
for  their  volume  often  gives  a  sense  of  comfort  to  the  stomach.     Only 


220  DISEASES  OP   THE  DIGESTIVE   TRACT 

the  tenderest  portions  of  asparagus  and  celery  should  be  allowed  pa- 
tients with  "stomach  trouble,"  as  they  call  it,  for  fragments  of  them 
can  usually  be  washed  out  of  the  stomach  the  next  morning  when 
eaten  the  evening  before  where  motility  is  but  slightly  impaired,  and 
the  long  fibers  often  pass  through  the  entire  tract  without  change,  and 
greatly  distress  patients  who  observe  their  stools,  who  think  them 
worms.  Their  power  of  "nagging"  the  intestine  to  response  is  the 
same,  however,  as  other  cellulose-containing  foods.  The  salads  made 
from  these  green  vegetables  should  never  be  allowed  where  there  is 
increased  gastric  secretion  or  impaired  motility,  because  of  the  use 
of  pepper,  vinegar,  mustard,  etc.,  which  stimulate  secretion.  A  let- 
tuce sandwich,  with  lemon  juice  alone,  may  sometimes  be  allowed. 
Potato  salad,  also,  should  be  excluded  from  the  diet  of  all  sufferers 
from  gastric  disorders.  As  practically  all  of  these  green  salads  simply 
serve  as  a  vehicle  to  carry  large  amounts  of  oil,  having  a  high  food 
value,  into  the  stomach,  this  deprivation  does  not  impair  nutrition, 
as  the  oil  can  be  taken  in  other  forms.  It  is  amusing  in  the  clinic 
to  note  the  instinctive  knowledge  possessed  by  the  poorer  people  where 
every  penny  counts,  of  the  lack  of  food  value  of  green  vegetables. 
Advice  to  use  salads  as  a  means  to  overcome  constipation  is  met  with 
a  shrug  of  the  shoulders  and  the  statement  that  they  cannot  afford 
it,  yet  the  dog  and  cat  instinctively  take  to  eating  grass  for  the  same 
conditions.  We  have  heard  much  of  the  loss  in  food  by  allowing  the 
mushrooms  of  the  fields  to  "waste  their  sweetness  (nutriment)  on  the 
desert  air,"  and  many  glowing  comparisons  are  made  between  them 
and  beefsteak  as  far  as  their  nitrogen  content  is  concerned,  but,  in  fact, 
mushrooms  contain  too  much  cellulose  to  be  readily  utilized  by  an 
impaired  digestive  tract,  and  are  largely  ballast,  besides,  unless  culti- 
vated from  an  approved  seed,  subjecting  the  consumer  to  a  possible 
poisoning. 

Fruit  and  berries  contain,  on  aji  average,  water,  84-90  per  cent,  pro- 
tein, 0.1-0.7  per  cent;  carbohydrate,  2-6  per  cent;  acid.  0.2-2.4  per 
cent ;  and  sugar,  1-10  per  cent ;  though  grapes  may  have  as  much  as  24 
per  cent  of  the  last.  These  sugars  may  be  glucose,  levulose,  and  cane 
sugar,  M'hile  fruit  may  also  contain  dextrin  and  pectin  substances.  For 
those  suffering  from  weak  digestions,  cooked  fruit  should  always  be 
recommended,  because  of  greater  ease  of  solution  and  the  softened  cel- 
lulose. The  acid  contained  also  plays  a  prominent  part,  and.  for  those 
having  a  tendency  to  heartburn,  apples  and  ripe  pears,  with  an  acid 
content  of  0.2-0.8  per  cent,  should  be  given  the  preference,  rather  than 
currants  and  oranges,  with  2.3-4  per  cent  of  acid.     Strawberries  vary  so 


DIETETICS  IN   DIGESTIVE   DISORDERS  221 

largely  in  this  respect  that  the  variety  in  the  early  spring,  shipped  from 
the  South  green,  can  hardly  be  compared  with  those  raised  in  the  vicin- 
ity of  the  consumer  and  allowed  to  ripen  on  the  vines.  The  author's 
advice  is  always  to  cook  the  former,  while  the  latter  may  be  eaten  raw. 
The  dried  fruits — apples,  prunes,  apricots,  and  tigs — can  be  given 
cooked  as  a  sauce  when  no  gastric  irritation  exists  for  their  decided 
effect  on  increasing  intestinal  peristalsis,  made  much  more  effective  by 
sweetening  with  molasses  and  less  irritating  to  the  stomach  by  being 
sieved — prune  puff,  etc.  Out  of  season  the  canned  fruits — or  fresh 
fruits  in  jars,  as  they  are  sometimes  called  to  distinguish  them  from 
the  preserved  form  (which  has  a  large  amount  of  sugar  added)  — 
served  with  cream,  form  an  admirable  substitute  for  cooked  new  fruit. 
The  exclusive  use  of  grapes,  the  ''grape  treatment"  so-called,  for 
obesity  and  high  blood  tension,  has  had  its  adherents,  but  it  is  prob- 
ably only  a  semistarvation  treatment,  for  it  may  be  always  noted  that, 
when  a  single  article  of  food  is  used,  the  patient  soon  begins  to  partake 
of  it  less  and  less.  The  recommendation  that  both  seeds  and  skins  be 
swallowed  is  not  without  its  dangers,  for  grape  skin  and  seeds  will 
remain  a  long  time  in  an  atonic  stomach.  Six  months  has  been  re- 
ported by  one  observer  for  the  seeds,  whose  entrance  into  the  appendix 
— though,  of  course,  enormously  exaggerated,  since  concretions  w^ere 
often  mistaken  for  them — is  to  be  avoided.  The  use  of  raisins  to 
test  gastric  motility  has  sprung  directly  from  these  observations.  The 
other  berries — raspberries,  gooseberries,  blueberries,  etc. — contain  a 
large  percentage  of  malic  and  citric  acids,  and  hence  are  less  de- 
sirable taken  as  such,  but  their  pressed  juice,  diluted  with  water, 
makes  an  admirable  drink,  and  is  less  liable  to  cause  "burning"  in 
the  stomach  in  those  susceptible  to  that  sensation,  probably  due  to  the 
stimulation  of  the  gastric  juice.  The  juices  of  blackberries,  cherries, 
and  huckleberries  have  won  some  renown  as  a  remedy  against  diarrhea, 
and,  while  the  latter  in  dried  form  can  be  easily  procured  abroad  and 
a  decoction  made  of  them,  they  cannot,  as  far  as  the  author's  knowl- 
edge extends,  be  procured  in  this  country. 

Xiits  generally  pose  as  indigestible,  and  are  unsuited  to  those  suf- 
fering from  gastric  insufificiency  or  irregularities  of  secretion.  Those 
cured,  as  reported,  in  a  marvelous  way  by  an  exclusive  nut  diet  have 
simply  undergone  a  period  of  undernutrition,  and  the  favorable  re- 
sults have  been  due  to  that.  From  sweet  almonds,  however,  an  emul- 
sion, which  is  officinal,  is  made  containing  protein,  fat,  and  sugar,  and 
which  as  an  adjuvant  to  forced  feeding  in  malnutrition  is  not  to  be  de- 
spised, besides  having  a  beneficial  effect  on  intestinal  catarrh;  but, 


222  DISEASES   OF   THE   DIGESTIVE   TRACT 

as  it  readily  spoils,  it  must  be  made  up  fresh.  The  acorn,  on  account 
of  its  5  per  cent  tannic  acid,  may  be  added,  when  ground,  to  coffee 
or  cocoa  to  overcome  the  laxative  effect  of  either,  on  account  of  its 
astringent  effect,  and  such  a  mixture  can  be  used  for  mild  intestinal 
catarrhs.  Abroad  this  mixture  goes  under  the  names  respectively  of 
acorn  coffee  and  acorn  cocoa. 

Sugar  must  not  be  omitted  from  the  carbohydrates,  first,  because  it 
is  a  widely  distributed  condiment,  and,  second,  because  of  its  marked 
food  value.  Formerly,  up  to  the  end  of  the  middle  ages,  it  was  re- 
garded only  as  a  medicine,  and  now  our  government  sends  tons  of  it, 
made  up. into  candies,  to  our  soldiers  in  the  Philippines.  We  employ 
grape,  milk,  fruit,  and  cane  sugars;  cane  from  the  sugar  cane  (in  the 
South  huge  stalks  are  found  at  the  grocery  doors  in  sections  where 
the  negro  does  his  own  refining)  and  from  the  beet;  grape  from  all 
fruit  and  honey,  and  milk  sugar,  of  course,  from  milk  and  cream.  Dif- 
ferent forms  of  sugar  are  only  valuable  for  their  flavor,  since  in  the 
great  melting  pot  of  the  body  they  all  become  grape  sugar.  Ac- 
cording to  various  authors,  sugar,  when  eaten,  excites  a  flow  of  dilut- 
ing fluid  from  the  blood  to  the  stomach  which  is  without  the  constit- 
uents of  gastric  juice,  and  hence  the  employment  of  several  lumps  of 
sugar  at  midforenoon,  midafternoon,  and  bedtime  have  proven  very 
valuable  in  gastric  hypersecretion,  with  ' '  burning, ' '  when  the  stomach 
is  empty,  in  many  of  the  author 's  patients.  E wald  allows  his  patients 
with  gastric  hemorrhage  to  first  take  sugar  water  by  mouth,  and  the 
famous  "honey  water"  of  Hippocrates,  employed  in  fever,  must  have 
depended  on  its  large  sugar  content  (30  per  cent)  for  its  therapeutic 
action.  The  sore  mouth,  of  which  individuals  sometimes  complain 
after  the  use  of  honey,  is  probably  due  to  the  formic  acid  deposited  by 
the  bees.  Since  honey  is  so  frequently  adulterated  with  glucose  syrup, 
perhaps  it  is  as  well  to  depend  on  the  thick  syrupy  extracts  of  malt, 
which  are  prepared  under  different  names,  and,  while  they  possess  no 
diastatic  power,  form  an  admirable  means  of  maintaining  the  daily 
calories  of  patients  who  possess  little  or  no  desire  for  food.  It  can  be 
taken  in  milk  or  on  bread  and  butter,  as  the  black  molasses,  dear  to 
our  childhood  days,  was.  At  present  all  imaginable  things  are  put 
in  the  malt  extracts,  but  they  are  worth  only  what  their  analytic  value 
in  maltose  shows. 

Condiments  were  formerly  regarded  as  mere  accessories  to  our 
food  and  not  necessities,  but  at  least  one,  salt,  has  been  proven  to  be 
absolutely  needful  for  a  sound  digestion.  When  salty  food  comes  in 
contact  with  the  mucous  membrane  of  the  mouth  only,  it  excites  a  flow 


DIETETICS   IN   DIGESTIVE   DISORDERS  223 

of  saliva,  and,  reflexly,  at  the  same  moment  of  gastric  juice,  an  occur- 
rence which  has  been  amply  proven  on  gastrostomized  dogs  and  hu- 
mans. There  are  those  who  insist  that  salt  in  the  stomach  produces 
an  alkaline  flow,  the  dilution  secretion,  instead  of  true  gastric  juice, 
but  this  is  true  only  of  large  doses  and  not  of  the  smaller  portions 
used  in  food  as  a  condiment.  Even  a  pinch  of  salt  in  the  morning 
glass  of  water  can  be  easily  demonstrated  to  incite  a  flow  of  gastric 
juice  when  this  secretion  is  impaired  (hypochlorhydria  and  achylia). 
Of  the  other  condiments — pepper,  mustard,  horseradish,  etc. — we  can 
only  say  that,  as  they  improve  the  flavor  of  food,  they  increase  its 
digestibility  because  of  the  reflex  activity  of  the  gastric  flow,  and  Mayr 
in  his  new  work  on  intestinal  torpor  (Darmtraegheit)  complains  that 
persons  accustomed  to  highly  seasoned  foods  require  much  more  Carls- 
bad water  to  produce  free  catharsis  than  others,  showing  that  condi- 
ments are  not  without  their  influence  on  peristalsis  of  the  intestine. 
This  fact  was  known  long  ago  to  Da  Costa,  who  called  red  pepper  the 
''whip  of  the  digestion."  Constant  use,  however,  of  these  irritating 
substances,  like  pepper  and  mustard,  cannot  fail  to  have  some  effect 
on  the  kidneys,  by  which  they  must  be  eliminated,  and  are  supposed 
by  some  to  have  an  effect  on  increasing  blood  tension.  Their  use 
should  be  forbidden  in  all  cases  of  hypersecretion  of  gastric  juice,  but 
in  achylia  the  free  use  of  red  pepper  has  served  the  author  admirably. 
In  later  times  saccharin  has  been  used  as  a  condiment  in  place  of 
sugar  by  the  obese  and  diabetics,  but  it  must  be  remembered  that,  un- 
like sugar,  it  has  no  food  value  whatever,  is  a  strong  antiseptic,  and  is 
not  well  borne  by  those  who,  in  conjunction  with  the  affections  men- 
tioned, have  a  "weak  stomach."  The  onion,  too,  like  sugar,  has  a 
double  function  of  condiment  and  food,  but  perhaps  is  oftener  used 
for  a  condiment  to  give  flavor  to  an  otherwise  tasteless  mixture.  On 
account  of  the  peculiar  oils  which  it  contains,  in  many  its  departure 
from  the  stomach  can  be  timed  by  the  cessation  of  eructations  of  its 
peculiar  mustard-like  oil.  After  this  arraignment,  as  the  Good  Gov- 
ernment Association  says  of  candidates,  we  do  not  recommend  its 
selection  where  there  is  any  impairment  of  digestion.  Ginger  has  won 
some  reputation  as  a  stimulus  to  gastric  digestion,  and  may  be  em- 
ployed both  as  a  condiment  in  food  and  as  a  medicine  where  gastric 
secretion  is  impaired,  but  for  flavoring  ice  cream,  cakes,  etc.,  a  little 
good  vanilla  meets  all  requirements. 


CHAPTER  VIII 
TREATMENT  OF  DIGESTIVE  DISORDERS 

Only  four  means  are  in  our  hands  for  the  management  and  con- 
trol of  the  individual  suffering  from  impaired  digestive  activities, 
either  functional  or  organic — diet,  physical  treatment,  medicinal  treat- 
ment, and  surgery — which  belongs  in  this  treatise  only  so  far  as  indi- 
cations for  its  employment  may  be  discussed.  Rarely  do  we  depend 
on  one  alone  of  these  means,  but  combine  two  or  more  in  our  efforts  to 
remedy  or  stay  the  patient's  disorder.  An  unfortunate  view  has 
sprung  up  that,  when  we  call  on  surgery  for  aid,  our  functions  as  in- 
ternists cease,  but,  in  the  author's  experience,  only  when  the  surgeon 
has  short-circuited  a  narrow  pylorus  by  a  gastroenterostomy,  or  sus- 
pended a  looped  colon  with  its  often  fantastic  configuration,  are  we 
able  to  bring  our  forces  most  fitly  and  effectually  into  play,  for  the 
mechanical  hindrance  which  has  brought  all  our  efforts  to  naught  is 
now  removed.  A  colon  catarrh  existing  for  years,  which  has  sec- 
ondarily invaded  the  appendix  and  forced  its  removal,  can  hardly  be 
expected  to  vanish  as  soon  as  the  latter  event  takes  place,  yet  that  is 
exactly  what  most  physicians  expect,  and  often  express  their  disgust 
at  surgery  because  the  patient  does  not  instantly  recover. 

DIETETIC  TREATMENT. 

Dietetic  treatment  of  digestive  disorders  comprises  the  careful  fol- 
lowing of  a  diet  list  prepared  by  the  practitioner,  not  by  the  manu- 
facturers of  some  patent  food,  in  which  that  food,  of  course,  plays  the 
most  conspicuous  part.  This  diet  list  should  tell  the  patient  what  to 
eat,  when  to  eat,  and,  briefly,  how  the  food  should  be  cooked  or  pre- 
pared. If  certain  articles  of  food  should  be  avoided,  that  also  may  be 
stated,  but  a  diet  list  which  contains  only  negatives  leaves  the  patient 
in  a  bewildered  state,  without  any  confidence  in  any  article  of  food. 
The  list  must  be  adapted  to  the  individual's  occupation,  both  as  to 
quantity  (laborer  or  clerk),  to  his  hours  (night  workers  who  sleep  by 
day) ,  and  often,  the  author  is  grieved  to  say,  to  his  pocketbook.  Then, 
again,  we  must  take  into  account  religious  restrictions — the  Hebrew, 

224 


TREATMENT   OF   DIGESTIVE   DISORDERS  225 

for  instance,  if  following  strictly  the  tenets  of  his  religion,  will  not,  of 
course,  eat  any  product  of  the  pig  or  oysters,  and  the  Catholic  de- 
clines meat  on  Friday.  Let  us  suppose,  for  example,  that  we  are  deal- 
ing with  a  sufferer  from  gastric  neurosis,  who  avoids  food,  because 
it  incites  distress  or  pressure  after  eating,  accompanied  by  palpi- 
tation and  subjective  throbbing  of  the  abdominal  aorta,  w^ho  has  no  re- 
ligious objections  to  any  kind  of  food,  and  can  remain  away  from  occu- 
pation or  business.  '  Such  an  individual  would  demand  more  calories 
than  a  condition  of  rest  would  otherwise  claim — viz.,  1,800;  in  other 
words,  a  "Mastkur, "  as  it  is  known  in  Germany,  and  on  account  of 
the  hyperesthesia  there  will  be  five  or  six  small  meals.  "VVe  also  take  it 
for  granted  that  examination  has  shown  no  marked  variation  from  the 
normal  in  secretion  or  motility.  Such  eases  we  meet  with  almost  daily. 
From  either  White's  or  Arnold's  charts  we  can  obtain  our  food  values 
in  household  measures,  and  our  diet  list  would  then  read  as  follows : 

DIET   LIST   IN    MALNUTRITION. 

Calories. 

Before  rising,  a  cup  of  hot  cocoa  should  be  taken,  made  of  a  teaspoonful 
of  Phillips'  digestible  cocoa  (50)  and  the  upper  portion  of  a  jar  of 
milk  (160).  A  couple  of  oatmeal  crackers  (60)  may  be  taken  with 
this   if   desired 270 

Breakfast. — Two  hours  after  the  first  cup  of  cocoa,  breaKfast  should  be 
taken  in  bed^ — half  a  grapefruit  (70),  or  an  orange  (75),  or  a  baked 
apple  (75)  with  two  tablespoonfuls  of  cream  (60),  (avoiding  skin  and 
seeds);  a  small  chop  (150),  or  egg  on  toast  (145),  or  omelet  of  two 
eggs  (150),  or  two  tablespoonfuls  picked  fish  and  cream  (130),  or  two 
slices  of  crisp  bacon  (70),  or  a  piece  of  broiled  tripe,  5x3  inches  (70), 
with  a  slice  of  toast  (70),  or  a  stale  roll  or  muffin  (70)  warmed  in  the 
oven.  Butter,  one  pat  or  ball  ( 80 ) ,  should  be  used  freely  on  every  ar- 
ticle of  food,  as  meat  and  bread.  After  the  meal  is  taken  a  cup  half  of 
cofl"ee  and  half  cream,  or  the  upper  part  of  a  can  of  milk  (180),  may 
be  taken    385 

11:30  a.m. — At  this  time  a  half  cup  of  beef  juice  (170),  made  by  express- 
ing the  juice  from  a  lightly  broiled  piece  of  steak  with  a  lemon  squeezer, 
should  be  taken  with  a  couple  of  saltines  (30)    200 

Dinner. — Xo  soup ;  broiled,  baked,  or  boiled  meat  or  fish,  piece  5  x  3  x  ^4 
inches  (150),  of  any  kind  desired,  without  the  gravy  (made),  but  with 
plenty  of  the  meat  juice.  This  meat  should  be  carefully  minced  with 
a  knife  by  attendant  or  patient,  or,  better,  put  through  a  meat  chopper. 
A  roll  and  a  pat  of  butter  (195),  two  heaping  tablespoonfuls  of  mashed 
potato  (80),  squash  (40),  spinach  or  cauliflower  cooked  in  two  table- 
spoonfuls of  cream  (60)  ;  two  heaping  tablespoonfuls  of  rice,  sago, 
tapioca,  bread,  or  custard  pudding  (160),  or  cooked  fruit  (140)  with 
a  tablespoonful  of  cream    (30) ,  average    610 

Jf  p.  m. — A  cup  of  custard    (275)   or  two  tablespoonfuls  of  good  ice  cream 


226  DISEASES   OF   THE   DIGESTIVE   TRACT 

(270),   eaten   slowly,   with   a   slice   of   stale   cake    (75)    or   two   sweet 

crackers     350 

Supper. — A  dropped  or  scrambled  egg  (75),  or  three-fourths  dozen  oysters, 
either  raw  or  cooked,  with  some  butter  and  flavored,  or  two  slices  each 
plain  or  cream  toast,  with  two  tablespoonfuls  of  picked  fish  (70),  or 
smoked  beef  in   cream    210 

2025 

Wnen  diets  are  cheeked  up  in  this  way,  one  is  often  surprised  to  find 
that  the  calories  sura  up  far  less  than  are  actually  required  to  keep  the 
patient  in  equilibrium.  Another  way,  suggested  by  W.  R.  P.  Emer- 
son, is  to  have  the  patient  keep  an  account  in  this  homely 'way  of 
household  measures,  of  what  and  how  much  he  eats  voluntarily,  which 
should  be  checked  by  these  tables,  when  many  an  individual  will  be 
found  to  be  undernourished.  It  is  not,  however,  merely  necessary  to 
check  up  calories,  but  an  examination  of  the  feces  should  always  be 
made  to  determine  which  ingredient  of  the  food  is  least  well  utilized, 
and  particular  attention  should  be  given  to  adapting  or  modifying  that 
form — be  it  fat,  protein  (meat),  or  starch — to  the  needs  of  the  weak- 
ened digestion  and  absorption  of  that  special  ingredient.  Many  a 
patient  may  be  taking  his  full  caloric  ration,  but  through  achylia — by 
which  meat  digestion  suffers,  or  fermentative  intestinal  dyspepsia  (A. 
Schmidt) ,  under  which  starch  digestion  labors — our  estimate  of  normal 
calories  is  sadly  shattered,  for  the  normal  percentage  of  waste  is  vastly 
exceeded.  This  emphasizes  most  strongly  that  we  can  go  on  blindly 
adhering  to  an  ideal  made  up  of  calories,  because  Rubner  has  shown 
that  even  in  health  a  potato,  possessed  of  a  certain  caloric  value,  im- 
parts vastly  more  to  the  body 's  needs  when  mashed  than  when  eaten  as 
a  salad.  A  mixed  diet  has  always  appealed  to  the  author  in  all  forms 
of  digestive  disease  as  particularly  adapted  to  the  needs  of  the  pa- 
tient, but,  as  we  have  so  many  advocates  of  sole,  single,  and  exclusive 
articles  of  food,  a  brief  consideration  should  be  given  them.  In  every 
case  a  single  article  of  diet  always  produces  inefficient  nourishment, 
and,  in  fact,  we  are  told  that  "Man  should  not  live  by  bread  alone." 

Milk  Diet. — Some  uncomplimentary  things  have  already  been  said 
of  this  exclusive  mode  of  nourishing  patients,  based  on  the  enormous 
quantity  demanded  and  its  insufficient  utilization.  We,  of  the  old 
regime,  who  have  seen  our  patients  waste  away  to  a  shadow  with  the 
combination  of  typhoid  and  exclusive  milk  diet,  all  of  which  we  at- 
tributed to  the  fever,  have  lived  to  see  a  bland  mixed  diet  employed 
and  the  horrible  emaciation  of  this  disease  checked.     For  gastric  and 


TREATMENT   OF   DIGESTIVE   DISORDERS  227 

duodenal  ulcer  in  their  active  form,  for  which  an  exclusive  milk  diet 
was  apparently  strictly  indicated,  the  Lenhartz  diet  has  shown  its 
greater  efficacy  in  checking  loss  of  weight  and  allowing  the  ulcer  to 
heal.  When  we  find  obesity  combined  with  gastric  hypersecretion  in 
business  men  and  others  who  are  accustomed  to  eat  well  and  drink  bet- 
ter, an  exclusive  milk  diet  works  admirably,  because  it  checks  the  ex- 
cess of  acid,  and  its  very  fault  (undernutriment)  is  demanded.  Apart 
from  the  conditions  mentioned,  a  diet  consisting  largely,  but  not 
wholly,  of  milk  serves  admirably  in  pyloric  stenosis;  chronic  gastritis 
due  to  circulatory  stasis;  intestinal  catarrh,  particularly  of  the  colon, 
on  account  of  its  little  residue,  if  the  digestive  juices  are  not  lacking ; 
the  dyspepsia  accompanying  anemia  and  ptosis,  and  certain  instances 
of  hypersusceptibility  of  the  gastric  mucous  membrane,  where  vomit- 
ing is  common  without  evidence  of  actual  disease.  This  milk  diet  may 
be  varied  by  the  addition  of  egg,  soft  cheese,  fruit  juices,  mashed  vege- 
table, or  baked  potato  and  cream  until  such  time  as  an  occasional  bit 
of  broiled  fish  or  chop  can  be  introduced.  Exclusive  or  largely  milk 
diet  is  prohibited  in  gastric  neurosis,  apart  from  the  nervous  vomit- 
ing mentioned,  for  in  every  case  the  individual  always  feels  much 
worse ;  in  fact,  the  strict  milk  diet  is  often  an  excellent  means  of  diag- 
nosis in  differentiating  the  former  condition  from  gastroduodenal 
ulcer,  which  always  gives  less  discomfort  to  the  patient  when  rest  and 
a  modified  milk  diet  is  employed.  Least  of  all  is  the  large  use  of  milk 
indicated  in  pure  atony  of  the  stomach,  due  to  relaxed  muscular  walls 
and  not  to  pyloric  narrowing,  for  this  relaxation  is  increased  by  the 
large  volume  of  the  milk.  Chronic  diarrheas  also  do  not  improve  on 
a  milk  diet,  though  putrefactive  changes  cease. 

Purely  Vegetarian  Diet. — The  purely  vegetarian  diet  hhs  many  ad- 
herents, but  very  few  carry  it  out  absolutely,  regarding  the  absence  of 
meat  as  constituting  a  vegetarian  diet,  but  allowing  milk,  cheese,  and 
eggs.  With  this  interpretation  we  can  agree  better,  for,  owing  to  the 
scanty  protein  content  of  the  purely  vegetable  diet,  it  produces  an  ex- 
cess of  fat  and  the  impairment  of  muscle.  Some  of  the  photographs 
of  the  babies  offered  to  induce  parents  to  invest  in  So-and-so's  food, 
known  to  be  almost  pure  carbohydrate,  prove  better  than  words  the 
truth  of  this  statement.  When,  however,  we  make  the  additions  men- 
tioned and  produce  a  lactovegetable  diet,  we  have  a  nutritious,  easily 
digested  combination,  adapted  to  many  conditions.  All  vegetables 
must  be  thoroughly  cooked,  for  one  can  have  no  patience  with  those 
who  insist  that  food  should  be  eaten  raw,  a  condition  of  affairs  so  abso- 
lutely opposed  to  all  the  proven  facts  of  the  chemistry  of  digestion. 


228  DISEASES   OF   THE   DIGESTIVE   TRACT 

Furthermore,  in  order  to  obtain  a  balanced  ration,  fat  in  the  shape  of 
good  butter  must  be  added  freely  to  all  vegetables,  or  oil,  taken 
abundantly  on  bland  green  vegetables,  like  lettuce  or  water-cress.  By 
the  addition  of  these  articles,  too,  we  raise  the  caloric  value  of  such  a 
diet  to  the  body  requirements  and  overcome  the  great  failing  of  the 
vegetable — insufficiency  of  nutritive  value.  The  advantages  of  the 
lactovegetable  diet  are  the  removal  of  the  xanthin  bodies  or  extractive 
substances  of  meat,  which  are  closely  allied  with  gouty  disorders,  the 
increase  of  arterial  tension,  and  the  formation  of  certain  varieties  of 
vesical  calculi.  Then,  furthermore,  the  intestinal  peristalsis  is  stimu- 
lated by  the  increased  amount  of  fecal  residue,  due  to  the  cellulose  as 
well  as  to  the  organic  acids  and  gases  formed  from  the  latter  by  means 
of  bacteria  in  the  colon.  How  much  the  psychic  effect  of  such  a  regi- 
men may  have  to  do  with  the  marked  improvement  seen  is  difficult  to 
say;  at  least  it  is  often  possible  to  withdraw  alcohol,  tea,  and  coffee 
when  the  patient  has  been  whipping  up  a  flagging  digestion  by  these 
means.  The  lactovegetable  diet  proves  most  efficacious  in  nervous  dys- 
pepsia, where  the  consciously  difficult  digestion  is  only  one  of  the  many 
symptoms,  such  as  insomnia,  vague  neuralgias,  or,  as  the  colored  people 
of  the  South  call  it,  ' '  the  misery  all  over, ' '  When,  however,  there  is  a 
gastric  motor  insufficiency  or  an  increased  secretion,  then  our  lacto- 
vegetable diet  fails  to  benefit  because  of  its  too  great  volume  and  too 
great  liability  to  incite  rather  than  check  the  flow  of  gastric  juice, 
which  in  turn  retards  the  digestion  of  the  starch  in  the  vegetable  food. 
Naturally,  from  what  has  been  stated,  this  form  of  diet  works  most 
excellently  in  constipation,  since  the  acids  and  gases  formed  stimulate 
peristalsis  in  the  colon  and  hasten  the  passage  of  feces  through  it.  In 
intestinal  neurosis,  where  vague,  mild  to  severe  pains  (which  only  too 
often  turn  out  to  be  arteriosclerosis  of  the  abdominal  vessels),  are  com- 
plained of,  this  diet  often  works  to  perfection,  relieving  the  spasm  of 
the  vessels,  which  is  claimed  to  be  the  cause  of  the  pain.  The  con- 
traindications' to  this  diet  are  diarrhea,  all  stenoses  of  the  tract,  and 
all  ulcerative  processes,  whether  of  the  stomach,  small  or  large  in- 
testine, although  Kelling  makes  use  of  it  for  the  purpose  of  establishing 
diagnosis,  either  by  increase  and  localization  of  pain  or  the  induction 
of  occult  hemorrhage. 

Salt-Free  Diet. — The  salt-free  diet,  apart  from  its  advantage  in  all 
edemas,  with  which  we  have  nothing  to  do  here,  has  been  employed 
sometimes  successfully  in  combating  hypersecretion  on  the  theory  that 
the  sodium  chloride  (from  which  the  hydrochloric  acid  is  made)  must 
come  from  the  blood,  and  anything  which  tended  to  diminish  that  re- 


TREATMENT   OF   DIGESTIVE  DISORDERS  229 

serve  would  reduce  the  acid  supply.  Furthermore,  as  a  gastric  or 
duodenal  ulcer  is  always  aggravated,  if  not  caused,  by  an  abundance 
of  hydrochloric  acid,  a  salt-free  diet,  which  in  reality  is  not  salt  free, 
but  with  a  very  restricted  salt  content,  has  proved  very  beneficial. 
Ordinary  articles  of  food,  arranged  in  a  table  as  eaten,  show  the  fol- 
lowing increasing  amounts  of  sodium  chloride  in  a  portion,  as  we  un- 
derstand it,  or  enough  for  one  person  for  one  meal: 


Amount  of  salt  in  one 
portion,  grams.  - 

Zwieback        ( 3 )     0.28 

White  bread   ( 3 )    0.37-0.52 

Gravies    0.28-0.6 

Dropped  eggs   0.5 

Cauliflower,   mashed   potato,   or   lettuce,   cucumber,   or 

celery  salad    0.5  -0.9 

Potato  soup  made  with  milk   0.7 

Bouillon     0.75-1.5 

Wheat  grits  or   cracked  wheat    1.7 

Roast    beef    or    chop     1.9  -2.8 

Scrambled  eggs   2.4  -2.7 

Asparagus     2.7  -3.5 


From  this  table  we  learn  that  foods  with  small  salt  content  are  eggs, 
cereals,  vegetables,  and  milk.  Butter  must  always  be  unsalted,  and 
bread  must  either  be  prepared  free  from  salt  or  zwieback  must  be 
used.  Soups  must  be  made  of  milk,  thickened  with  potato  or  flour, 
while  bouillon  must  be  avoided.  All  vegetables  must  be  boiled  in 
water,  without  salt,  and  a  teaspoon ful  of  meat  extract  may  be  added 
for  flavoring.  Potato  must  either  be  baked  or  mashed,  and  eaten  with 
cream  and  without  salt.  Salads  may  be  prepared  with  oil  and  lemon 
juice.  Eggs  may  often  be  taken  raw,  well  beaten,  with  sugar,  and 
perhaps  a  dash  of  nutmeg.  Light  puddings  of  flour  may  be  made, 
without  salt,  and  be  eaten  with  a  sauce  containing  some  fruit  juice, 
when  the  absence  of  salt  will  not  be  noticed.  How  far  this  restriction 
in  the  use  of  salt  may  be  carried  can  be  learned  only  from  experience, 
and  depends  largely  on  the  patient.  Some  can  get  along  with  two 
grams  daily,  while  others  with  five  grams  will  show  the  effects  of  the 
abstinence,  which  consist  of  a  distaste  to  the  unsalted  food,  which  may 
become  so  great  that  patients  refuse  all  food.  At  least  it  is  always  de- 
sirable to  make  a  trial  of  this  diet  when  a  gastric  ulcer  and  its  ac- 
companying hypersecretion  exists. 


230  DISEASES   OF   THE   DIGESTIVE   TRACT 

PHYSICAL  TREATMENT  OF  DIGESTIVE  DISORDERS. 

Physical  treatment  of  digestive  disorders,  next  to  dietetic,  plays 
the  most  important  part,  comprising,  as  it  does,  the  employment  of 
water,  gymnastics,  and  electricity. 

Hydrotherapy. — Hydrotherapy,  in  spite  of  its  vast  effects  in  medi- 
cine, is  too  little  emphasized  in  teaching  that  subject  and  too  little 
understood.  After  seeing  the  magnificent  hydrotherapeutic  establish- 
ment at  the  Eppendorf  hospital  at  Hamburg,  one  looks  in  vain  in  our 
country  for  an  equal  establishment.  Still,  in  a  small  way,  institutes 
are  being  established  in  the  larger  cities,  and  meantime  we  can  carry 
out  in  the  poorest  dwellings,  at  least  in  those  that  have  running  water 
and  a  fair  pressure,  a  modified  hydrotherapeutic  treatment  that,  while 
not  ideal,  serves  our  purpose  very  well. 

1.  The  morning  cold  sponge  or  rub  is  perhaps  the  simplest  form  of 
procedure,  and  one  which  will  be  most  generally  employed.  The  pa- 
tient should  dash  water  at  a  temperature  of  52°  F.  over  the  entire 
body,  or  squeeze  the  water  from  a  sponge,  paying  particular  attention 
to  the  abdomen.  Better  still,  the  water  may  be  poured  from  a  pitcher 
over  the  body,  after  which  the  body  is  to  be  rubbed  with  a  wet  towel 
and  slapped  with  the  corners  of  the  towel  until  the  skin  is  well  red- 
dened. Of  course,  if  such  bath  is  taken  in  a  bathing  establishment, 
this  manipulation  is  done  by  an  attendant,  but  the  special  advantage 
of  this  treatment  is  that  it  can  be  carried  out  without  aid  on  rising. 
The  process  should  not  last  more  than  five  minutes,  and  then  the 
body  should  be  well  dried  with  a  Turkish  towel  or  so-called  elephant 
mit.  The  theoretical  advantage  of  this  treatment  is  the  engorgement 
of  the  surface  blood  vessels  and  the  consequent  abstraction  of  the  blood 
from  the  visceral  ones ;  hence  it  is  particularly  applicable  in  catarrhal 
conditions  of  the  stomach  and  intestines.  In  my  personal  experience 
it  has  proven  especially  valuable  as  a  substitute  for  the  plunge,  which 
is  preferable,  but  will  not  be  employed  by  many  patients  in  that  great 
class  called  neurotics,  with  a  marked  leaning  toAvard  digestive  discom- 
fort, like  pressure  after  eating  and  a  feeling  of  weariness  and  overdis- 
tention  of  the  abdomen  by  gas  in  the  morning.  Of  course,  one  has 
to  combat  the  preconceived  notions  of  the  patient  as  to  taking  cold, 
too  much  shock  to  the  nervous  system,  etc.,  but  ordinarily,  with  a  little 
persuasion,  except  in  the  most  confirmed  hydrophobics,  the  treatment 
will  be  carried  out  faithfully.  When,  however,  the  patient  complains 
of  much  lassitude  after  the  cold  rub,  and  declares  that  it  takes  two 
hours  and  more  to  get  warm  in  spite  of  the  brisk  rubbing,  it  must  be 


TREATMENT   OF   DIGESTIVE   DISORDERS  231 

temporarily  foregone,  but  should  be  resumed  as  soon  as  increased 
nutrition  has  improved  blood  conditions,  for  those  who  make  such  com- 
plaints are  either  so  sluggish  that  any  surprise  like  the  shock  of  cold 
water  is  distasteful  to  them,  or  else  are  really  anemic  and  reaction  does 
not  promptly  take  place, 

2.  The  needle  spray  is  another  means  of  application  of  water,  in 
which  the  temperature  of  the  water  should  alternate  between  hot  and 
cold,  but  should  end  in  cold.  In  all  bath  establishments  and  dressing 
rooms  of  gymnasia,  as  well  as  in  most  of  the  homes  of  the  rich,  this 
apparatus  is  installed,  but  its  particular  value  is  its  application  imme- 
diately on  rising,  and  here  such  institutions  are  of  no  avail.  Fortu- 
nately, a  spray  apparatus  has  been  devised  and  is  sold  at  small  cost 
which  can  be  applied  by  a  divided  hose  and  two  rubber  nipples  to  any 
bath  tub,  thus  giving  the  poor  all  the  advantages  of  the  rich  in  this 
respect.  This  spray  should  be  applied  particularly  to  the  abdomen 
for  three  to  five  minutes,  and  its  action  is  that  of  a  thermic  massage. 
To  me  it  has  proved  most  valuable  in  atonies  of  the  stomach  without 
pyloric  narrowing,  and  unquestionably,  by  inducing  later  stronger 
and  more  prolonged  peristaltic  action,  causes  the  organ  to  be  emptied 
more  promptly.  It  also  induces  peristaltic  action  in  the  intestine  and 
often  a  desire  for  stool. 

3.  The  plunge  naturally  follows  the  cold  rub  after  the  latter  is 
practiced  for  a  short  time,  and  consists  in  filling  the  tub  with  water 
from  the  cold  faucet,  either  at  the  time  of  rising  or,  in  case  of  the  par- 
ticularly timid,  the  night  before,  whereby  the  water  assumes  the 
temperature  of  the  room,  and  then  wetting  the  whole  body  by  rolling 
over  two  or  three  times  in  the  cold  water,  after  which  the  patient 
wraps  himself  in  a  warm  bath  towel  and  waits  for  the  reaction,  which 
comes  almost  immediately  in  the  form  of  a  glow  and  sense  of  well- 
being,  often  followed  by  an  appetite  for  breakfast.  This  form  of  bath 
is  particularly  indicated  in  those  who  awake  with  a  dull  head  and  a 
feeling  of  lassitude — as  they  express  it,  ' '  as  tired  as  when  they  went  to 
bed,"  a  ''dark-brown  taste"  in  the  mouth,  and  no  desire  for  food. 
After  a  sleepless  night,  too,  it  is  surprising  how  the  plunge  will  re- 
juvenate the  jaded  nerves.  Gastric  neuroses  where  no  definite  de- 
parture from  the  normal  laws  of  secretion  and  motility  are  found  often 
yield  gracefully  to  this  treatment  when  all  others  have  failed. 

4.  The  warm  sitz-bath,  or  hip-bath  (95°-104°),  proves  most  effective 
in  lowering  the  acute  nervous  tension  under  which  many  of  these 
victims  of  nervous  dyspepsia  suffer,  and  stops  spasm  of  the  pylorus 
or  intestine,  either  of  central  origin  or  due  to  a  local  ulcer  or  its  scar. 


232  DISEASES   OF   THE   DIGESTIVE   TRACT 

Many  an  incurable  malignant  disease  can  be  relieved  of  its  sting  for 
the  night  by  placing  the  patient  in  a  hot  hip-bath  for  five  minutes  be- 
fore retiring,  for  at  least  a  part  of  all  pain  in  these  cases  is  due  to 
spasm  of  a  portion  of  the  organ  in  which  the  growth  is  situated.  Then, 
again,  the  painful  sensations  accompanying  membranous  or  mucous 
colitis,  as  you  choose  to  call  it,  and  of  cholecystitis,  particularly  in  the 
latter,  if  accompanied  by  the  needle  spray,  can  be  allayed  by  the  hot 
hip-bath.  Of  course  this  does  not  imply  that  real  gallstone  colic  can 
be  relieved  by  any  such  means,  but  in  conjunction  with  sedatives  it 
helps,  and  during  an  attack  the  bath  tub  is  the  best  place  for  the 
victim.  Furthermore,  this  form  of  bath  before  retiring  has  enabled 
me  to  defer,  and  often  avoid,  the  use  of  hypnotics  in  that  twin  sister  of 
nervous  dyspepsia,  insomnia,  unaccompanied  by  pain,  but  associated 
with  a  most  active  mind  and  great  restlessness.  i\Iy  experience  with 
the  cold  hip-bath  is  nil,  for  the  application  of  cold  in  any  form,  in  my 
mind,  must  be  accompanied  by  action  to  resist  its  possible  injurious 
effect,  and  to  remain  thirty  minutes,  as  recommended  by  some,  sit- 
ting in  cold  water  (unless  there  is  temperature  of  fever  present)  seems 
rather  barbarous. 

5.  Cold  applications,  made  by  wringing  out  a  towel  of  cold  water, 
wrapping  it  about  the  abdomen,  and  covering  with  a  dry  one,  both  to 
be  fastened  with  a  safety  pin,  until  the  former  is  warmed  and  dried 
by  the  heat  of  the  body,  causes  theoretically  a  contraction  of  the  blood 
vessels  and  stimulation  of  the  peripheral  nerves.  Actually  it  is  often 
the  needed  stimulus  for  the  after-breakfast  defecation,  and  is  espe- 
cially indicated  in  women  who  have  borne  many  children,  have  lax 
abdominal  walls  and  moderate  prolapse  of  the  abdominal  organs.  It 
is  often  well  to  repeat  the  application  once  during  the  morning  period 
before  dressing,  while  attending  to  the  innumerable  things  associated 
with  a  lady's  toilet.  Others  prefer  to  make  the  application  at  night, 
and  many  times  fall  asleep  with  the  cold  pack  around  their  abdomens, 
and,  ' '  post  hoc  ergo  propter  hoc, ' '  declare  it  the  sovereign  remedy  for 
insomnia.  Hot  packs  can  be  applied  after  the  manner  of  our  fore- 
fathers— by  flaxseed  poultices  or  by  several  thicknesses  of  flannel 
wrung  out  of  hot  water,  which,  of  course,  must  be  changed  every  five 
to  ten  minutes;  by  the  hot  water  bag  or  thermophore,  which  is  now 
made  in  shapes  to  fit  the  contour  of  the  abdomen  closely,  and  will  re- 
tain water  at  any  temperature  for  a  long  period  of  time ;  or  by  the 
electric  pad  where  a  current  is  available,  which  by  means  of  a  switch 
can  be  maintained  at  different  degrees  of  temperature,  but  is  very  ex- 
pensive, both  as  regards  the  instrument  and  the  amount  of  current 


TREATMENT   OP   DIGESTIVE  DISORDERS  .  233 

used.  When  moist  heat  is  employed,  it  is  well  to  apply  vaseline  to  the 
patient's  abdomen,  to  prevent,  if  possible,  any  superficial  burns,  and  a 
clotheswringer  will  be  fully  appreciated  by  the  nurse  who  has  to 
wring  out  the  hot  cloths.  The  thermophores  are  chiefly  objectionable 
on  account  of  their  weight,  particularly  when  applied  to  the  abdomen, 
but  this  has  been  overcome  largely  by  employing  wood  alcohol,  which 
will  retain  its  heat  for  hours  in  such  an  instrument.  It  is  needless  to 
say  that  alcohol  must  always  be  warmed  by  dipping  its  container  in 
hot  water.  The  effect  of  these  hot  packs,  whether  dry  or  moist,  is.  to 
quiet  pain  and  produce  a  hyperemia  of  the  organs  lying  under  the 
skin  and  a  better  circulation  through  them.  Therefore  we  use  them 
for  gastroduodenal  ulcer  where  no  hemorrhage  has  occurred  within  a 
week,  for  appendicitis,  intestinal  catarrh  associated  with  diarrhea  and 
periodic  colic-like  spasms,  and  sometimes  for  constipation  due  to 
spasm.  Whenever  bleeding  is  present  anywhere  in  the  tract,  the  hot 
pack  is  contraindicated,  and  the  cold  application  wins  its  own,  either 
applied  as  an  ice  bag  or,  again,  the  thermophore  filled  with  ice  water. 
These  cold  applications  are  also  desirable  where  there  is  active  inflam- 
mation associated  with  pain,  tenderness,  and  heat. 

Mineral  Waters. — Mineral  waters  have  had  their  vogue  in  the 
treatment  of  digestive  disorders,  but,  as  each  water  has  induced  the 
erection  of  a  sanitarium  at  the  site  of  the  spring  from  which  it  comes, 
where  more  attention  is  always  paid  to  the  amount  of  water  consumed 
than  to  diet  and  exercise,  these  waters  have  never  accomplished  what 
they  should.  There  has  always  been  a  certain  air  of  mysticism  asso- 
ciated with  mineral  water  drinking,  as  if  they  could  accomplish  vastly 
more  at  the  spring  than  similar  waters  compounded  accurately  after 
the  chemical  formula  of  the  former. 

The  action  of  mineral  waters  on  digestive  disorders  depends  on 
the  temperature,  the  amount  taken,  its  content  in  carbon  dioxide,  and 
the  amount  of  the  dissolved  salt  which  is  absorbed.  (1)  Both  hot  and 
cold  mineral  waters  increase  peristalsis  of  the  entire  tract  as  well  as 
its  secretion,  but  do  not  increase  the  flow  of  bile.  (2)  The  carbon 
dioxide  increases  the  blood  pressure,  produces  diuresis,  and  has  a  mild 
anesthetic  action  on  the  stomach,  but  does  not  in  any  way  increase 
the  secretions.  (3)  The  action  of  the  dissolved  salts  (sodium  and 
potassium  chloride;  sodium,  magnesium,  and  calcium  carbonate; 
magnesium  and  sodium  sulphate;  iron  and  arsenic  compounds) 
depends  largely  on  the  concentration;  if  greater  than  that  of  the 
blood,  mineral  waters  remain  a  much  larger  time  in  the  stomach 
and   cause   a    flow    of   fluid    from   the   blood   to   the   tract,   thereby 


234  DISEASES   OP   THE   DIGESTIVE   TRACT 

producing  fluid  evacuations.  Whether  the  radioactivity  of  the  waters 
has  any  influence  is  difiicult  to  say.  Bickel  and  others  thought 
pepsin  was  increased,  but  the  waters  must  be  drunk  at  the  spring, 
for  the  radioactivity  of  mineral  water  disappears  forty-eight  hours 
after  its  removal  from  its  source.  There  is  still  in  the  medical 
profession  a  certain  amount  of  superstitious  awe  concerning  radium, 
which,  apart  from  quantities  large  enough  to  actually  produce  burns, 
is  much  as  faith  is  described,  ''the  substance  of  things  hoped  for,  the 
evidence  of  things  not  seen. ' '  Hence  we  shall  confine  ourselves  strictly 
to  those  waters  which  have  a  clearly  defined  action  and  may,  be  em- 
ployed therapeutically  to  combat  certain  circumscribed  pathological 
conditions,  and  these  are  very  limited  in  number : 

1.  Mild  alkaline  waters,  which  contain  sodium  bicarbonate  and  car- 
bon dioxide,  like  Vichy  (Celestins),  which  has  5.1  parts  per  1,000  of 
the  salt  and  532  parts  of  free  carbon  dioxide;  Saratoga  Vichy,  which 
has  2.2  parts  of  the  salt  per  1,000  and  1824  parts  of  carbon  dioxide. 
Thus  we  see  that  the  imported  water  has  more  sodium  carbonate,  bu^ 
much  less  carbon  dioxide.  Then,  the  artificial  Vichy  of  the  soda  foun- 
tain or  as  sold  in  siphons,  if  made  of  pure  materials,  has  practically 
the  same  solution.  In  the  Newer  Formulary  we  also  have  Sal  Vichy- 
anum  Faetitium,  which,  when  1  gram  is  added  to  a  glass  (200  e.c.)  of 
water,  produces  a  similar  effect.  The  use  of  these  waters  is  confined 
to  mild  gastric  hypersecretions,  as  it  neutralizes  the  acid  without  in 
any  way  increasing  such  secretion.  Their  power  to  dissolve  mucus 
or  stimulate  the  flow  of  bile,  as  claimed,  has  never  been  demon- 
strated. 

2,  The  alkaline  laxative  waters  contain  sodium  sulphate  and  chlor- 
ide, sodium  carbonate,  and  free  carbon  dioxide.  The  ones  in  common 
use  are  the  Carlsbad  (Sprudel),  which  at  the  spring  has  a  tempera- 
ture of  144.8°  F.,  so  that  elsewhere,  when  the  imported  article  is 
used,  it  is  usually  heated  to  that  point  before  it  is  taken.  Our  best 
substitute  for  the  foreign  article  is  Bedford  Springs  water,  which 
has,  however,  only  10  parts  of  magnesium  sulphate,  and  the  former  10 
parts  of  sodium  phosphate,  while  the  Carlsbad  has  much  more  sodium 
carbonate.  We  have,  however,  the  evaporated  salts  from  the  genuine 
Sprudel  water,  which,  unfortunately,  are  now  being  freely  advertised 
to  the  public  in  the  newspapers,  and  also  Sal  Carolinum  Faetitium,  N. 
F.,  which,  in  my  experience,  gives  just  as  good  results,  when  a  gram 
is  dissolved  in  a  cup  of  hot  water,  as  either  the  imported  water  or  the 
salt.  Yet,  to  those  who  can  afford  it  a  stay  either  at  Bedford  Springs, 
Pa.,  or  Carlsbad  is  to  be  recommended  for  the  change  and  regimen 


TREATMENT   OP   DIGESTIVE   DISORDERS  235 

carried  out  at  both  places.  Just  what  the  physiological  effect  of  these 
waters  on  digestion  is  has  never  been  fully  demonstrated.  Some 
claim  diminution  of  gastric  secretion,  while  others  fail  to  find  it; 
many  claim  an  increase  of  motility,  while  others  again  could  not 
demonstrate  it.  TheJ^efore,  the  miraculous  effects  of  the  treatment  of 
gastric  disorders  at  Carlsbad  by  the  waters  alone  have  fallen  into  dis- 
repute, but  we  are  willing  to  give  the  physicians  there  credit  for  re- 
lieving many  patients  of  their  functional  digestive  disorders,  and 
perhaps  some  organic,  by  methods  of  which  probably  drinking  the 
water  plays  but  a  minor  part.  After  personal  observation  of  the 
treatment  at  Homburg,  with  its  saline,  sulphur,  and  iron  springs,  it 
appeared  to  me  that  the  regular  life,  restricted  diet,  exercise,  beauti- 
ful music,  and  mountain  air  had  as  much  to  do  with  the  improve- 
ment as  the  vaunted  water  drinking.  We  can,  however,  send  only  a 
small  percentage  of  our  patients  to  the  springs,  so,  as  in  the  case  of 
Mahomet  and  the  mountain,  though  reversed,  the  springs  must  come 
to  us,  and,  laying  aside  any  veneration  for  the  spring  water  not  based 
on  its  chemical  analysis,  we  must  prescribe  it  only  in  conjunction 
with  diet,  exercise,  amusement,  and  regular  life,  when  we  shall  ob- 
tain the  results  our  Carlsbad  brethren  do.  When  the  Carlsbad  treat- 
ment is  given  at  home,  it  is  very  necessary,  too,  that  the  exact  time 
when  the  water  is  to  be  taken  should  be  specified,  as  well  as  its  amount 
and  temperature.  Usually  it  is  best  to  give  two  glasses,  fasting,  about 
twenty  minutes  apart,  and  half  an  hour  after  the  last  glass  breakfast 
is  to  be  taken.  The  patient  may  remain  quiet  or  move  about  during 
the  drinking,  though  at  the  springs  exercise  is  recommended.  For 
dispensary  practice,  where  economy  is  an  object,  the  artificial  Carlsbad 
will  accomplish  the  same  results  as  the  imported  mineral  water,  apart 
from  the  adjuvant  means  employed  with  drinking  at  the  springs. 
Now  the  Carlsbad  treatment  is  indicated  (1)  in  all  cases  where  there 
is  hypersecretion  of  gastric  juice;  (2)  in  all  chronic  gastric  and 
duodenal  ulcers;  (3)  in  chronic  catarrh  of  the  small  intestine,  in  small 
doses  and  very  hot;  (4)  in  the  diarrhea  following  chronic  dyspepsia; 
(5)  in  chronic  atonic  constipation,  given  cold.  On  the  contrary,  we 
should  not  employ  it  (1)  in  acute  diseases  of  the  tract  (bleeding  ulcer 
of  the  stomach  or  duodenum,  acute  enteritis,  or  appendicitis)  ;  (2)  in 
dilated  stomach  due  to  benign  or  malignant  pyloric  obstruction;  (3)  in 
gastrointestinal  neurosis;  (4)  in  achylia  gastrica;  (5)  in  any  malig- 
nant disease  of  the  intestine.  Those  suffering  from  nervous  dj^spepsia, 
who  form  at  least  75  per  cent  of  one's  practice,  are  particularly  un- 
suited  to  the  Carlsbad  treatment,  and  are  invariably  made  worse  if  it 


236  DISEASES  OF   THE   DIGESTIVE   TRACT 

is  attempted,  so  that  it  can  be  readily  seen  that  one  must  be  excessively 
careful  in  the  selection  and  that  comparatively  few  *  *  are  chosen. ' ' 

3.  Saline  waters  contain  chiefly  sodium  chloride  and  carbon  dioxide. 
The  Kissingen  springs  are  the  most  popular  abroad,  and  we  have  ap- 
proved the  treatment  so  much  that  we  have  introduced  into  the  ' '  Newer 
Formulary ' '  Sal  Kissingense  Factitium,  from  which  the  mineral  water 
can  be  readily  made  by  adding  a  gram  to  a  cup  of  water  (Rakoczi 
Spring),  The  Congress  Spring  at  Saratoga  Springs,  New  York,  fur- 
nishes water  of  the  same  general  composition.  The  action  of  this 
water  is  based  on  no  scientific  facts,  but  seems  to  be  used  empirically. 
It  dissolves  mucus  in  the  stomach,  stimulates  appetite,  and  increases 
the  secretion  of  hydrochloric  acid.  The  free  chlorine  ions  in  the  in- 
terior of  the  organ  provide  the  chief  basis  for  the  existence  of  hydro- 
chloric acid,  and  the  strong  saline  waters,  by  producing  a  flow  of  the 
diluting  fluid  from  the  blood  to  the  interior  of  the  stomach,  diminish 
the  acidity  of  the  latter 's  contents,  and  because  not  reabsorbed  they 
produce  fluid  evacuations.  The  chief  indications  for  the  use  of  this 
water  are  anacid  gastric  catarrh  and  achylia  gastrica,  which  is  so  com- 
monly of  nervous  origin.  It  is  claimed  that  a  return  of  hydrochloric 
acid  often  follows  the  use  of  Kissingen  or  Congress  water,  but  my  testi- 
mony cannot  be  added  to  that,  pro  or  con,  for,  when  that  fortunate 
event  has  happened  to  me  with  patients,  drinking  the  waters  has  been 
only  a  part  of  the  treatment.  Of  course  this  applies  only  to  the  func- 
tional forms  of  achylia.  Actual  experiment  with  dogs  gastrostomized 
by  Pawlow's  method  shows  that  with  these  saline  waters  gastric  secre- 
tion is  increased  74  per  cent  beyond  what  it  is  with  ordinary  water. 
As  stated,  in  large  doses  the  waters  produce  free  movements,  and  hence 
are  indicated  for  colon  catarrh  associated  with  constipation.  These 
waters  should  never  be  used  in  case  of  gastric  ulcer,  nervous  dys- 
pepsia, atony,  and  dilatation  of  the  stomach,  or  in  any  form  of  cancer 
of  the  tract. 

4.  Bitter  waters  are  those  containing  sodium  sulphate  and  chloride, 
and  magnesium  sulphate.  They  are  represented  chiefly  by  Hunyadi 
Janos  and  Apenta  abroad,  and  Red  Raven  and  Pluto  water  from 
French  Lick  Springs,  Indiana,  in  this  countrj^  though  the  claim  has 
been  made  by  the  Council  on  Pharmacy  and  Chemistry  of  the  Ameri- 
can Medical  Association  that  the  last-named  is  fortified  by  the  addi- 
tion of  magnesium  sulphate. 

These  purgative  waters  are  not  absorbed,  but  pass  to  the  lower  in- 
testinal tract,  where  they  absorb  water  from  the  blood  on  account  of 
their  higher  osmotic  index  and  stimulate  peristalsis,  as  a  result  of 


TREATMENT   OF   DIGESTIVE   DISORDERS  237 

which  they  promptly  produce  a  liquid  stool  soon  after  taken.  At  the 
springs  they  are  always  cold,  and  should  be  taken  that  way  apart 
from  the  springs;  hence  their  use  is  confined  to  an  occasional  morn- 
ing dose  before  breakfast  for  producing  a  loose  stool  when  hemorrhoids 
are  present,  or  after  a  too  hearty  meal  the  evening  before,  or  for  the 
purpose  of  driving  out  tapeworm.  On  the  contrary,  these  waters 
should  never  be  used  in  any  acute  inflammation  of  the  tract,  whether 
of  the  stomach  (ulcer)  or  of  the  intestine  (appendicitis).  The  amount 
should  not  exceed  one  glass. 

The  iron  spring  waters,  though  recommended  for  the  anemia  asso- 
ciated with  chronic  ulcer,  achylia  gastrica,  etc.,  have  never  proven  of 
any  benefit  in  my  practice.  Levico,  an  arsenical  water,  however,  has 
apparently  in  these  conditions  been  able,  with  the  aid  of  iron-contain- 
ing food  (or  possibly  the  latter  alone),  to  restore  the  hemoglobin  to  its 
normal  percentage  much  sooner  than  without  its  use. 

Climatic  Influences. — Climatic  influences  often  play  an  important 
part  in  the  relief  of  those  forms  of  indigestion  which  have  a  large 
nervous  element  associated.  Whether  the  change  of  climate  should 
be  to  the  mountains  or  shore  seems  much  a  matter  of  indifference,  so 
long  as  luxury  and  strain  are  exchanged  for  ' '  roughing  it, "  as  we  call 
camping,  and  freedom  from  care.  Astounding  as  it  may  seem,  food 
which  an  individual  with  impaired  digestion  would  look  on  with 
horror  at  home  is  eaten  with  relish  in  a  camp  at  the  ocean  side  or  in 
the  mountains,  and  digested  without  discomfort.  The  frying  pan  is 
used  without  discretion  and  self-rising  flours  (which  never  rise)  cause 
no  complaint.  This  immunity  in  camp  is,  however,  confined  to  the 
nervous  dyspeptic,  as  he  is  called,  a  product  largely  of  our  American 
rush,  and  does  not  justify  any  such  risk  with  the  person  suffering 
from  a  chronic  gastroduodenal  ulcer.  The  seashore,  too,  has  won  well- 
merited  renown  for  the  relief  of  these  same  dyspeptics,  particularly 
where  the  daily  dip  in  the  ocean  may  be  indulged  in.  This  does  not 
apply,  however,  to  the  palatial  hotels  at  the  seaside  where  life,  if  any- 
thing, proceeds  at  a  faster  pace  than  at  home,  and  where  excessive  eat- 
ing, dancing,  and  long  hours  spent  sitting  on  a  piazza  in  a  lethargic 
mood,  digesting  like  a  saurian  the  excess  of  food  which  has  been  pre- 
viously swallowed,  do  not  aid  in  any  way  to  overcome  the  difficulty 
for  which  the  patient  was  sent  to  the  seashore.  Better  a  crust  in  the 
open  than  a  Lucullus  feast  under  a  roof.  The  seashore  offers  greater 
atmospheric  pressure,  freedom  from  dust,  moisture,  and  an  increased 
content  of  the  air  in  salts  as  well  as  ozone,  all  of  which,  with  the  bath, 
offer  a  tonic  which  proves  most  advantageous  for  anemia  associated 


238  DISEASES   OF   THE   DIGESTIVE    TRACT 

with  functional  dyspepsia,  as  well  as  for  nervous  diarrhea,  which  is 
especially  benefited  by  a  stay  at  the  seashore.  Certain  restrictions 
must  be  impressed  on  patients  with  reference  to  bathing  in  the  ocean 
in  order  to  obtain  the  greatest  therapeutic  effects  and  not  to  cause 
harm.  One  should  never  take  a  bath  at  once  on  arrival,  but  had  best 
wait  two  or  three  days  before  beginning.  One  should  not  bathe 
early  while  fasting,  and  should  not  remain  longer  in  the  water 
than  ten  minutes,  though  this  does  not  exclude  the  custom  of  a 
sun  bath  in  the  sands  and  a  return  to  the  water  afterward.  The 
best  time  is  at  flood  tide,  and  for  very  feeble  persons  the  salt  water 
should  be  warmed,  as  is  customary  in  most  bathing  resorts.  Under  the 
influence  of  these  salt  baths  the  appetite  is  usually  aroused  to  its  ut- 
most, and  patients  must  be  warned  against  too  early  complete  gratifica- 
tion. It  is  much  better  to  indulge  in  the  11  a.  m.  and  4  p.  m.  lunch 
than  to  eat  at  the  three  regular  meals  all  one  cares  for.  The  sea  baths 
are,  on  the  other  hand,  contraindicated  where  the  patient  suffers  from 
arteriosclerosis,  any  disease  accompanied  by  fever,  acute  gastrointes- 
tinal catarrh,  and  cholelithiasis.  On  our  own  Atlantic  coast  Atlantic 
City,  Fortress  Monroe,  and  Palm  Beach  have  won  great  renown  for 
winter  and  autumn  resorts,  while  Old  Orchard,  Newport,  Nantucket, 
and  Bar  Harbor  have  become  famous  for  summer  resorts,  but,  as  far 
as  that  is  concerned,  the  whole  of  New  England  is  studded  with  small 
resorts  and  islands,  and  the  purse  must  be  slim  indeed  which  will  not 
allow  its  possessor  a  short  stay  at  one  of  these  places.  Why  speak  of 
the  inferiority  of  the  accommodations  at  these  places  to  those  of  one's 
home  ?  It  is  a  change  and  a  rest,  and  the  crudeness  of  the  surround- 
ings too  often  adds  only  zest  to  the  enjoyment.  It  is  the  bitter  expe- 
rience of  many  a  physician  to  have  recommended  a  residence  at  some 
resort  to  an  individual  and  to  be  compelled  to  listen  to  reproaches  be- 
cause the  accommodations  were  not  such  as  the  patient  had  at  home. 
]\Iuch  the  same  is  true  of  the  mountain  resorts.  The  patient  is  often 
benefited  by  the  air  and  life  in  the  open,  but,  unless  he  be  of  the  type 
mentioned  and  possess  no  actual  organic  disease,  he  had  best  be  sent  to 
a  sanitarium,  where  proper  food  and  cooking  can  be  acquired,  as  a 
chronic  ulcer  of  the  tract,  an  early  and  undiagnosed  cancer  (as  many 
are),  or  a  chronic  enteritis  will  not  show  any  improvement  on  the 
products  of  the  frying  pan.  ^ly  experience,  however,  limited  to 
Poland  Springs  House  and  Woodstock  Inn,  places  kept  open  all  winter, 
is  that  a  diet  sent  with  the  patient  will  be  fairly  closely  followed  by 
the  chef.  This  course  seems  much  better  than  to  send  those  in  whom 
the  digestive  organs  are  at  fault  to  sanitariums  where  neurasthenia  is 


TREATMENT   OF   DIGESTIVE  DISORDERS  239 

chiefly  treated,  and  where  they  have  notions  of  their  own  in  regard  to 
diet  and  your  own  receive  scant  attention.  Then,  further,  at  both 
winter  and  summer  resorts  at  the  seashore  or  in  the  mountains  your 
patients  are  surrounded  by  cheerful  individuals,  bent  on  sport,  which 
is  encouraged  in  every  way,  instead,  as  at  a  sanitarium,  of  long-faced, 
whining  persons,  who  congregate  only  to  compare  their  symptoms  and 
weigh  their  importance,  and,  much  as  at  a  temperance  meeting  where 
the  one  who  can  tell  of  the  worst  degradation  is  looked  on  with  awe  by 
his  neighbors,  the  patients  who  have  lost  most  organs  by  surgery  or 
been  nearest  death  are  venerated  by  the  group.  Sanitariums  are  only 
for  the  most  hardened  criminals  in  breaking  the  laws  of  health,  while 
an  ocean  or  mountain  resort,  with  possibly  a  nurse  to  see  that  your 
instructions  are  carried  out,  is  much  better  fitted  for  the  majority  of 
patients  with  digestive  disorders.  But  what  shall  we  do  with  the 
poor  who  cannot  afford  the  luxury  of  these  resorts?  Well,  in  our 
section  of  the  country  they  have  answered  that  for  themselves,  and 
many  a  shack  or  discarded  car  from  the  old  horse  railroad  days  perched 
along  the  shore  contains  a  family  in  whose  number  is  one  or  more 
weaklings,  who,  coddled  with  condensed  milk  and  the  various  arti- 
ficial foods  in  the  tenements  of  the  city,  are  able  to  devour  their  hot 
biscuits  and  bacon  with  impunity.  Nor  is  only  this  section  blessed  in 
this  way.  Anyone  entering  the  cities  or  Berlin  or  Vienna  will  be 
struck  by  the  small  shacks,  many  of  them  beautified  by  climbing 
flowers,  and  the  small  piece  of  cultivated  land,  occupied  by  the  city 
dwellers  who  often  have  only  Sundays  to  acquire  health,  yet  possess 
a  sound  digestion  and  sounder  sleep.  This  same  movement,  intro- 
duced by  Mayor  Pingree  of  Detroit,  should  be  imitated  by  every 
municipality.  Call  it  change  of  climate,  which  it  can  hardly  be,  since 
only  ten  miles  separate  the  shack  from  the  tenement  home;  call  it 
change  of  surroundings  or  the  out-of-doors  occupation — many  a  func- 
tional dyspeptic  has  been  restored  to  health  by  it  when  the  formulary 
of  every  clinic  has  been  exhausted. 

Massage. — ^Massage  is  also  employed  advantageously  in  digestive 
diseases,  both  as  general  massage  and  that  particularly  applied  to  the 
abdomen.  The  first  action  of  this  method  of  treatment,  both  during 
and  after  it,  is  on  the  metabolism,  by  which,  as  a  result  of  the  in- 
creased circulation  of  the  blood,  more  nitrogenous  waste  is  eliminated 
and  absorption  becomes  more  active.  Many  are  skeptical  of  this 
method  of  treatment  because,  though  the  intestine  may  be  readily 
reached  by  the  masseur's  hands,  the  stomach  lies  largely  under  the 
ribs  and  the  liver.     But  this  is  only  under  normal  conditions;  in  pro- 


240  DISEASES  OP   THE   DIGESTIVE   TRACT 

lapse  of  the  stomach  the  organ  is  wholly  exposed  to  the  hands,  and 
here  massage  accomplishes  its  greatest  victory,  for  the  abdominal 
walls  are  usually  lax  and  the  stomach  atonic.  The  most  common  in- 
dication for  abdominal  massage  is  atony  of  the  stomach  and  colon, 
accompanied  by  infrequent  stools.  Furthermore,  in  conjunction  with 
this  method  of  treatment,  all  other  methods  must  be  employed,  for 
it  is  no  cure-all.  In  addition,  the  patient  must  be  willing  to  have 
this  treatment  continued  for  months,  for  a  four  weeks'  treatment  is 
worse  than  useless.  Massage  is  contraindicated  (1)  soon  after  a 
gastric  hemorrhage,  or  when  occult  blood  is  freely  present  in  the  stool ; 
(2)  in  all  forms  of  malignant  disease  of  the  tract,  particularly  when 
accompanied  by  stenoses;  (3)  any  attack  of  appendicitis,  if  the  ap- 
pendix was  not  removed,  precludes  the  use  of  abdominal  massage  for 
years  after  the  attack  (Zweig).  It  has  never  been  my  practice  to 
massage  my  patients,  as  is  recommended  by  many,  since  in  both  pri- 
vate practice  and  in  all  clinics  we  have  admirably  trained  practitioners 
of  this  art,  mostly  trained  in  Sweden.  Still,  each  physician  should 
have  enough  knowledge  of  the  subject  to  intelligently  direct  the 
masseur  what  to  do,  and  Bum's  description  and  illustrations  make  the 
matter  clear. 

The  abdominal  massage  is  best  carried  out  three  hours  after  a  meal 
and  with  an  empty  bladder.  The  patient  lies,  with  the  upper  half 
of  his  body  slightly  raised,  on  a  hard  surface,  and  the  practitioner  sits 
at  his  right.  The  technie  consists  chiefly  in  kneading  the  abdominal 
walls  and  the  intestinal  parts  adjacent,  for  all  we  can  hope  to  accom- 
plish is  the  restoration  of  tone  to  abdominal  muscles  and  the  flat 
muscles  of  the  tract. 

The  first  sitting  should  be  devoted  to  accustoming  the  patient  to  the 
relaxation  of  the  reflex  abdominal  muscle  contraction  under  the  mas- 
saging hand,  a  feat  best  accomplished  by  laying  the  hand  flat  on  the 
abdomen  in  the  region  of  the  navel,  and  making  circular  motions  to 
the  right  with  the  finger  tips,  directed  against  the  right  floating  ribs 
of  the  patient  (Fig.  50). 

With  moderate  pressure,  as  the  hand  turns  on  the  wrist  as  an  axis, 
the  hand  is  contracted  until,  when  the  motion  is  completed,  the  fingers 
point  toward  the  left  inguinal  region  of  the  patient  (Fig.  51). 

Now  the  abdomen  should  be  kneaded  in  both  a  horizontal  and  vertical 
direction  with  both  hands,  grasping  portions  between  the  thumb  and 
finger  tips,  and  also  between  the  base  of  the  hand  and  all  the  fingers, 
including  the  thumb,  endeavoring  always  to  reach  as  deeply  as  pos- 
sible (Fig.  52). 


TREATMENT  OF  DIGESTIVE  DISORDERS 


241 


Fig.  50.— Abdominal  massage,  first  manipulation. 


Fig.  51. — Abdaminal  massage,  second  manipulation. 


242 


DISEASES   OF   THE   DIGESTIVE   TRACT 


Fig.  52. — Abdominal  massage,  third  manipulation. 


Fig.  o3. — Abdominal  massage,  fourth  iii;uiipulation. 


TREATMENT   OF   DIGESTIVE   DISORDERS 


243 


Fig.  54. — Abdominal  massage,  fifth  manipulation. 


Fig.  oo. — Abdominal 


.sixth  iiiaiiiinilalioii 


244 


DISEASES   OF   THE   DIGESTIVE   TRACT 


Fig.  56. — Abdominal  massage,  .-scveiitli  ujanipulation. 


Fig.  57. — Abdominal  massage,  eighth  manipulation. 


TREATMENT   OF   DIGESTIVE   DISORDERS 


245 


We  now  proceed  to  the  massage  of  the  colon,  which  is  accomplished 
by  pressing  the  first,  second,  and  third  fingers  of  the  left  hand  upon 
the  abdomen  as  deeply  as  possible  with  the  free  hand,  and,  with  the 
pressure  maintained,  make  boring  motions,  always  getting  deeper  and 
deeper,  trying  to  compress  the  colon  between  the  abdominal  wall  and 
the  posterior  wall  of  the  pelvis.  These  motions  should  be  intermittent, 
and,  beginning  in  the  ileocecal  region,  those  parts  should  be  chosen 


Fig.  58. — Abdominal  massage,  ninth  manipulation. 


for  this  kneading  process  where  feces  are  liable  to  accumulate — viz., 
ascending  colon  and  hepatic  and  splenic  flexures  (Fig.  53). 

Now  along  the  whole  length  of  the  colon  stationary  kneading  fol- 
lows progressively  one  after  another  (Fig.  54). 

Now  follows  a  series  of  gliding  strokes  over  the  colon,  with  one  hand 
still  over  the  other  to  exert  greater  pressure,  and  always  in  the  direc- 
tion of  the  course  of  the  feces  (Figs.  55  and  56). 


246  •  DISEASES   OF    THE   DIGESTIVE   TRACT 

This  should  be  followed  by  shaking  the  abdominal  wall,  as  in  elicit- 
ing sueeussion,  by  vertical  cautious  strokes  with  the  finger  tips  or 
lightly  closed  fist  (Fig.  57). 

■We  complete  the  process  by  compressing  the  abdomen  with  light 
blows  from  the  finger  tips  of  each  hand  alternately  (Fig.  58). 

All  these  motions  should  be  carried  out  lightly,  and  the  patient 
should  never  experience  pain  from  them,  or  more  mischief  than  good 
may  be  done,  even  if  no  actual  danger  accompanies.     Furthermore,  as 


Fig.  59. — Portable  electric  vibrator. 

such  motions  may  be  made  almost  limitless  in  scope,  each  practitioner 
soon  learns  to  devise  new  motions  which  are  better  suited  to  his  needs. 
It  is  usual  in  digestive  disorders  to  massage  the  whole  abdomen. 
There  are,  however,  certain  diseases  of  the  stomach  per  se — such  as 
atony,  gastroptosis,  gastrectasis,  and  nervous  dyspepsia — where  mas- 
sage should  be  confined  to  the  stomach  region  alone.  In  this  case  the 
organ  must  not  be  empty,  nor  should  it  be  fully  distended,  two  to 
three  hours  after  the  last  meal  being  the  best  time.  Of  course,  when 
the  organ  lies  in  its  normal  position  under  the  ribs  of  the  left  side. 


TREATMENT   OF   DIGESTIVE   DISORDERS  247 

massage  cannot  reach  it,  but,  apart  from  a  few  cases  of  gastric  neurosis, 
where  there  is  no  displacement  and  where  the  employment  of  massage 
is  useless,  the  organ  is  usually  under  the  manipulator 's  hands,  at  least 
in  part,  in  these  conditions.  The  motions  of  stroking,  kneading,  and 
shaking  should  be  carried  out  as  in  the  case  of  the  lower  abdomen, 


Fig.  60.— Crank  vibrator,  with  pulsating  cushion. 

but  more  gently.  Where  individuals  cannot  obtain  massage  easily, 
as  during  departure  from  the  city  in  summer  or  from  lack  of  means, 
the  mechanical  vibrators,  sold  at  drug  stores  and  instrument  houses, 
are  very  satisfactory.  They  are  of  two  kinds,  one  which  can  be 
readily  attached  to  an  electric  light  socket,  and  the  other  an  instru- 
ment which  is  driven  by  a  crank. 

Electrical  Treatment. — The  electrical  treatment  of  digestive  dis- 
orders maintains  its  popularity,  though  no  actual  scientific  evidence 
exists  for  its  action  on  the  digestive  tract.  We  use  either  the  galvanic 
or  faradic  current,  and  apply  it  either  cutaneously  or  internally,  or 
use  a  combination  of  both ;  in  the  last  case,  a  broad  electrode  is  placed 
over  the  abdomen  and  electrodes  are  introduced  either  into  the  stom- 
ach or  the  rectum.  By  different  authors  it  has  been  claimed,  and  de- 
nied by  experiments  on  animals  and  humans,  that  electric  current  in- 
creases both  secretion  and  motilitj^ — clearly  a  case  of  "Donny  did  and 
Donny  didn't" — while  later  enthusiasts,  like  Riegel,  Boas,  and  Ein- 
horn,  claim  neither  increase  of  secretion  nor  motility,  but  speak  of 
its  general  beneficial  effect  on  the  nerves  and  muscles  of  the  stomach, 
implying  apparently  that  it  takes  the  nerve  out  of  nervous  dyspepsia, 
for  the  prolapse  or  the  atony  nevertheless  remains.  Whatever  may  be 
said  of  its  inability  to  perform  actual  work  in  increasing  motility  or 
secretion,  many  derive  some  benefit  from  it,  and,  as  the  gastric  neuro- 
sis is  so  intractable,  we  are  entitled  to  any  means  for  its  subjection, 
even  if  the  means  is  a  species  of  suggestive  therapeutics. 


248  DISEASES   OF   THE   DIGESTIVE   TRACT 

There  are  two  ways,  as  stated,  of  applying  electricity  for  these 
cases — extragastric  and  intragastric.  For  the  former  a  large  well- 
padded  and  moistened  electrode  should  be  applied  to  the  upper  ab- 
domen from  pylorus  to  fundus,  and  another,  separated  from  the 
former  by  a  space  of  1-2  cm.,  from  the  fundus  to  the  vertebral  column. 
The  current,  which  is  most  satisfactory  when  derived  from  the  in- 
candescent light  current  and  reduced  to  medical  needs  by  the  rheostat, 
should  be  used  in  considerable  strength — the  galvanic,  10-20  milli- 
amperes,  and  the  faradic,  or  interrupted,  strong  enough  to  cause  smart 
contractions  of  the  abdominal  muscles.  The  application  should  be 
continued  from  five  to  ten  minutes,  and,  if  the  galvanic  current  is  used, 
particular  care  must  be  taken  that  no  bare  metal  of  the  electrode  comes 
in  contact  with  the  skin,  for  it  has  been  my  experience  to  produce  mild 
burns  even  with  this  very  low  amperage  w^hen  such  precautions  have 
been  neglected.  A  combination  of  electricity  and  massage  can  be  em- 
ployed to  advantage  by  laying  a  plate  electrode  over  the  sternum  and 
as  a  second  electrode  using  an  electric  roller,  which  with  moderate 


Fig.  61. — Intragastric  electrode. 

pressure  is  passed  from  the  fundus  to  the  pylorus  several  times.  As 
there  is  still  some  question  whether  the  effect  of  electricity  on  diges- 
tive disorders  is  not  a  species  of  suggestive  therapeutics,  my  choice  is 
always  the  faradic  current,  because  the  noisy  interruption  of  the  in- 
duced current  appeals  also  to  the  ear,  and,  as  many  a  patient  has 
remarked,  seems  as  if  it  "  were  actually  doing  something. ' ' 

Intra,gastric  Electricity. — Intragastric  electricity  may  be  applied 
by  several  methods  which  have  been  devised.  Almost  every  manu- 
facturer of  electric  apparatus  lists  a  sound  more  or  less  modified  from 
Bardet's  or  Boas',  which,  after  the  patient  has  swallowed  a  glass  of 
water  to  prevent  burning,  may  be  inserted  and  the  current  turned  on. 

Einhorn  modified  this  method  by  devising  a  metal  button,  covered 
with  a  hard  rubber  shell,  perforated  with  small  holes,  and  allowed 
the  metal  to  communicate  with  the  fluid  in  the  stomach;  in  turn  the 
button  was  connected  by  a  fine  well-insulated  wire  with  the  source  of 
electrical  energy ;  after  drinking  a  glass  of  water  the  electrode  was  to 


TREATMENT   OF   DIGESTIVE   DISORDERS  249 

be  swallowed,  the  pad  was  to  be  placed  over  the  stomach,  the  negative 
wire  attached  to  the  former,  and  the  current  turned  on. 

Wegele  has  also  devised  an  electrode,  which  has  the  advantage  that 
it  may  be  introduced  into  any  stomach  tube,  consisting  of  a  metal  wire, 
a  guard  which  can  be  moved  up  and  down  the  wire  and  clamped  in 
position,  having  also  an  orifice  for  the  insertion  of  the  current  wire 
and  a  second  clamp,  and  at  the  end  a  metal  button.  First,  this  wire 
is  to  be  inserted  into  the  stomach  tube  and  the  guard  adjusted  so  that 
the  button  shall  be  1  cm.  above  the  first  opening  of  the  Jacques  tube 
and  clamped  to  the  wire.  Then  it  is  to  be  withdrawn,  the  soft  rubber 
tube  inserted  into  the  stomach  (the  latter  washed  out  if  necessary), 
a  small  quantity  in  any  event  poured  into  the  stomach,  when  the  ad- 
justed wire  is  now  introduced  into  the  tube,  the  connecting  wire 
(negative)  attached,  the  other  wire  connected  with  a  large  flat  elec- 
trode over  the  abdomen,  and  the  current  started. 

E  inborn  recommends  an  eight-minute  duration  of  treatment  and  the 
galvanic  current  of  a  strength  of  15-20  milliamperes,  but  patients  have 


c 


J 


Fig.  62. — Wegele's  intragastric  electrode. 

often  complained  to  me  of  a  current  stronger  than  10  milliamperes. 
As  to  electrodes,  Einhorn's  is  difficult  to  swallow,  the  stiff er  ones  after 
Bardet's  model  uncomfortable  to  retain  in  the  esophagus  for  eight  to 
ten  minutes,  while  the  most  convenient  of  all  is  Wegele's  which  is 
rarely  listed  by  our  instrument  makers.  The  intragastric  application 
has  largely  been  given  up  by  me,  except  faradism  for  relaxed  cardia, 
where  the  gastric  contents  come  tumbling  out  around  the  tube  in- 
stead of  through  it,  and  where  the  patient  complains  of  heartburn 
with  a  normal  or  lessened  hydrochloric  acid  and  no  fermentation. 
The  cutaneous  application,  however,  deserves  much  more  general  ap- 
plication in  gastric  neuroses,  call  its  effects  what  one  will,  but  has 
been  brought  into  disrepute  by  the  so-called  electric  specialists,  who 
have  employed  it  for  every  form  of  gastric  disease  and,  naturally, 
without  effect  in  many.  For  gastric  atony  and  gastroptosis  without 
pyloric  stenoses  it  may  be  tried,  but  never  to  the  exclusion  of  other 
means  of  treatment,  and  my  faith  in  its  efficacy  is  like  the  grain  of 
mustard  seed.     The  general  principle  in  the  use  of  electricity  in  gas- 


250  DISEASES   OF   THE   DIGESTIVE   TRACT  ' 

trie  disorders  is  faradism  for  motor  disturbances  and  galvanism  for 
sensory  anomalies,  gastralgia,  etc.,  and  for  hypersecretion, 

^lany  intestinal  disorders,  too,  may  be  benefited  by  electricity,  per- 
haps to  a  greater  extent  than  gastric,  though,  as  before,  scientists 
leave  us  in  confusion  as  to  the  real  physiological  action,  if  any  takes 
place,  at  least  with  an  atonic  colon  and  constipation.  Triumphs  and 
failures  have  been  mine,  but,  while  employing  electricity  in  such  cases, 
it  has  never  been  my  custom  to  lose  sight  of  other  means  of  accomplish- 
ing my  purpose.  A  similar  rectal  electrode  has  been  devised  by 
Zweig,  which  has  the  double  advantage  that  a  lumen  for  fluids  re- 
mains open,  controlled  by  a  cock,  so  that  fluid  like  water  or  s'alt  solu- 
tion may  be  poured  into  the  rectum,  the  cock  closed,  and  a  faradic 
current  passed  through  the  contained  spiral  wire  by  means  of  a  clamp, 
to  which  the  negative  wire  of  the  electrical  supply  should  be  applied. 

For  the  abdomen  the  massaging  roll  is  best  adapted,  which 
should  follow  the  course  of  the  colon.     Muscular  contractions  are  set 


Fig.  63. — Zweig' s  rectal  electrode. 

up  freely  in  the  abdominal  muscles,  and  the  sphincter  ani  is  found 
spasmodically  contracted  about  the  electrode,  which,  after  a  sitting,  is 
often  withdrawn  with  difficulty;  in  fact,  one  of  my  unpleasant  ex- 
periences was  to  have  the  electrode  (which  was  not  new)  separate  on 
account  of  the  tension  and  one  portion  remain  in  the  rectum.  Of 
course  the  accident  was  speedily  remedied,  but  it  proves  the  sphincter 
contraction.  No  permanent  relief  of  functional  constipation — and  by 
that  is  meant  what  is  due  to  an  atonic  colon — can  be  expected  unless 
the  electrical  treatment  is  continued  for  weeks,  but  most  individuals 
will  state  that  peristalsis  as  recognized  by  borborygmi — is  set  up  soon 
after  each  treatment,  and  often  some  haste  for  a  lavatory  for  the  sub- 
sequent imperative  defecation  is  demanded.  \Yith  the  Zweig  electrode 
the  galvanic  current  cannot  be  applied  on  account  of  its  metal  tip, 
which  may  burn  the  mucous  membrane,  but,  as  faradism  is  the  only 
current  which  can  apparently  arouse  the  sluggish  gut  to  activity, 
this  defect  is  not  felt.  The  cutaneous  application  of  electricity,  par- 
ticularly of  galvanism,  to  the  abdomen  proves  useful  in  colickj^  at- 


TREATMENT   OF   DIGESTIVE   DISORDERS 


251 


tacks  when  not  associated  with  stenosis,  flatulence,  and  tormina  intes- 
tinorum.  One  electrode  (positive)  should  be  placed  over  the  sternum 
and  the  broad  cathode  over  the  abdomen.  The  cutaneous  use  of  fara- 
dism  for  constipation  has  not  merits. 

Washing  out  the  stomach  has  been  mentioned  in  Chapter  V  as  a 
means  of  detecting  stasis  after  an  evening  Riegel  meal.  Here  we  wish 
to  consider  the  therapeutic  value  of  the  process,  introduced  first  by 


Fig.  64. — Gastric  lavage,  introduction  of  the  tube  with  head  bowed. 

Kussmaul  in  1867,  as  a  relief  for  the  evils  of  pyloric  stenosis.  Prob- 
ably no  method  of  treatment  has,  however,  been  so  abused  as  this. 
There  is  hardly  a  gastric  disease,  functional  or  organic,  for  which 
Penzoldt  in  his  work  on  therapy  does  not  recommend  gastric  wash- 
ing. Therapy  in  his  hands  is  restricted  more  closely  than  in  those 
of  the  otologists,  who,  as  the  late  Dr.  Richardson  used  to  say,  washed 
out  one  ear  and  blew  up  the  other.  At  present  tliis  method  of  treat- 
ment is  applicable  only  when  food  remnants  (stasis),  or  gastric  juice 


252  DISEASES   OP   THE   DIGESTIVE   TRACT 

(continuous  secretion),  or  much  mucus  (gastritis)  is  found  in  the 
fasting  stomach.  All  tales  of  spraying  the  stomach  through  a  tube 
with  centipede-like  openings,  or  the  use  of  the  gyromele,  by  which  you 
can  brush  your  stomach  as  you  would  your  teeth,  never  appealed  to 
me  as  having  any  other  effect  than  a  sensation  of  comfort  on  the  part 
of  the  practitioner  that  he  was  doing  something.  If  the  stomach,  when 
empty,  remained  like  a  gold  fish  globe,  spraying  and  brushing  would 


Fig.  65. — Gastric  lavage,  filling  the  funnel. 

be  feasible,  but,  as  it  collapses  as  the  food  leaves  it,  much  as  a  hot 
water  bottle  when  water  is  removed,  its  toilet  must  be  left  to  nature. 
In  washing  out  the  stomach  not  over  500  c.c.  should  be  introduced 
at  a  time,  which  must  be  returned  before  any  more  is  poured  in ;  the 
water  should  be  tepid,  and  may  have  a  tablespoonful  of  liquor  anti- 
septicus  alkalinus,  N.  F.  added  to  a  liter  of  it ;  the  funnel  should  be 
lowered  each  time  when  the  water  is  poured  in  and  then  raised,  but 
never  allowed  to  completely  empty  before  a  new  portion  is  added, 


TREATMENT   OF   DIGESTIVE   DISORDERS  253 

SO  that  air  may  not  be  driven  in.  The  stomach  should  be  washed  until 
the  water  flows  out  clear,  with  the  exception  of  bile,  which  is  usually 
mixed  with  it,  and  the  tube  should  be  withdrawn  before  the  water 
has  entirely  ceased  to  flow,  so  that  a  bit  of  gastric  mucous  membrane 
may  not  be  drawn  into  the  eye  of  the  tube  and  torn  off.  Apart  from 
the  purely  gastric  disorders  mentioned,  to  which  we  may  also  add  the 
less  common  acute  dilatation  for  which  gastric  lavage  is  indicated. 


Fig.  66. — Gastric  lavage,  filling  the  stomach  by  gravity. 

we  have  intestinal  stenosis  or  ileus  accompanied  by  fecal  vomiting, 
which  is  often  vastly  benefited  by  the  same  process,  which  removes 
fecal  matter  and  gases  above  the  narrowed  portion,  lessening  peri- 
stalsis and  rigidity  with  the  cessation  of  vomiting.  Uremic  vomit- 
ing also  may  sometimes  be  allayed  better  by  lavage  than  by  any  other 
means.  Contraindications  to  lavage  are  the  same  as  those  to  the  in- 
troduction of  the  tube  mentioned  in  Chapter  V.  It  sometimes  hap- 
pens that,  owing  to  the  great  atony  of  the  stomach,  the  water  does  not 


254 


DISEASES   OF   THE   DIGESTIVE   TRACT 


return  promptly.  If  one  is  convinced  that  this  is  not  due  to  an  oc- 
clusion of  the  tube  by  some  fragment  of  food,  which  can  be  easily 
told  by  pouring  another  small  portion  of  water  into  the  funnel  and 
noting  whether  it  flows  into  the  stomach,  it  may  be  found  necessary 
to  place  the  patient  in  a  recumbent  position,  when  very  often  the 
flow  will  be  reestablished,  accompanied  by  food  remnants.  In  an 
hourglass  stomach  we  may  apparently  have  washed  the  stomach  clean, 


Fig.  67. — Gastric  lavage,  emptying  the  stomach  by  siphonage. 

when  suddenly  another  mass  of  food  remnants  will  appear  in  the 
wash  water,  a  very  significant  sign  of  this  condition.  Innumerable 
substances  have  been  suggested  as  adjuvants  to  the  wash  wat(!r  in 
the  hope  of  adding  a  medicinal  as  well  as  a  mechanical  effect  to  its 
action.  These  are  sodium  bicarbonate,  2-5  per  cent,  for  gastritis; 
sodium  chloride,  same  amount,  for  achylia;  and  Carlsbad  salts,  silver 
nitrate  (1:1,000),  or  protargol  (0.5  per  cent),  for  hypersecretion; 
antiseptic  substances,  thymol   (14  per  cent),  resorcin   (2  per  cent). 


TREATMENT   OF   DIGESTIVE   DISORDERS  255 

boric  acid  (3  per  cent),  sodium  salicylate  (1  per  cent),  and  ichthyol 
(1  per  cent)  have  been  added  to  overcome  fermentation  in  dilatation 
accompanied  by  stenosis,  but  my  preference  is  for  liquor  antisepticus 
alkalinus,  N.  F.,  as  stated,  which  serves  all  needs  as  an  alkali  and 
antiseptic,  both  of  which  effects  must  be  very  slight  on  account  of  the 
short  stay  of  the  fluid  in  the  stomach.  With  the  addition  of  bitter 
substances  our  experience  is  nil.  Zweig  recommends  a  tablespoonful 
of  fluid  extract  of  condurango  added  to  500  c.c.  (pint)  of  warm  water, 
and  allows  the  liquid  to  remain  a  minute  in  the  stomach  before  it  is 
withdrawn. 

Rectal  injections  or  clysters  are  employed  for  4  distinct  purposes : 
(1)  to  empty  the  lower  bowel,  (2)  for  treatment  of  colon  catarrh, 
(3)  for  introduction  of  medicinal  agents,  (4)  maintenance  of  nutri- 
tion. 

The  evacuation  of  the  lower  howel  may  be  accomplished  by  water 
alone,  which  is  best  introduced  at  a  temperature  of  72°  F.  (lukewarm) 
or  64°  F.,  or  lower,  by  means  of  the  fountain  syringe  through  a 
soft  rectal  tube,  with  the  patient  on  the  left  side.  The  water  must  not 
be  used  too  hot,  for  powerful  reflex  contractions  are  set  up  and  it  can- 
not be  retained.  The  amount  should  not  exceed  500  c.c.  (1  pint), 
and  should  be  retained  ten  minutes  before  it  is  ejected.  Ice  water 
injections  are  very  beneficial  for  hemorrhoids  and  gastrointestinal 
hemorrhages,  causing  reflexly  an  arterial  spasm.  The  soap  and  water 
injection  is  an  old  household  procedure,  but  no  soap  should  be  em- 
ployed with  too  great  prodigality,  a  piece  as  large  as  the  end  of  the 
thumb  to  a  pint  of  water  sufficing;  nor  should  it  be  of  the  highly 
perfumed  kind,  because  in  the  former  case  too  much  alkali  is  intro- 
duced, which  acts  as  an  irritant  and  causes  too  great  contraction,  which 
ejects  the  water  without  fecal  matter,  and  in  the  latter  ease  because 
nitrobenzol,  a  virulent  poison,  is  often  used  for  perfuming  cheap  soaps. 
The  glycerine  injection,  consisting  of  20-25  grams  (a  tablespoonful), 
may  be  introduced  by  a  straight  syringe,  may  be  employed  as  a  sup- 
pository, which  is  much  more  convenient,  or  may  be  added  to  soap 
and  oil.  ^ly  favorite  is  a  pint  of  warm  water,  a  piece  of  soap  the 
size  of  a  walnut,  and  2  tablespoonfuls  each  of  glycerine  and  cotton- 
seed or  castor  oil.  This  fulfills  the  double  purpose  of  softening  the 
feces  and  producing  vigorous  contractions.  When,  however,  patients 
are  suffering  from  hemorrhoids  or  anal  fissure,  the  glycerine  should 
not  be  used.  When,  as  often  happens,  the  water  refuses  to  flow 
through  the  rectal  tube,  the  latter  should  be  withdrawn  somewhat, 
which,  by  straightening  it,  causes  the  lumen  to  be  restored  and  the 


256  DISEASES   OP   THE   DIGESTIVE   TRACT 

water  enters  quickly.  The  pure  oil  injections,  introduced  by  Fleiner, 
have  been  used  very  generally  in  constipation  caused  by  colon  catarrh 
and  in  colpoptosis,  because,  unlike  all  drastic  laxatives,  they  do  not 
aggravate  the  catarrh.  An  outfit  consisting  of  a  metal  irrigator,  be- 
cause the  oil  soon  destroys  rubber,  a  connecting  tube  (4  feet  in  length), 
and  a  rectal  tube  with  a  glass  union,  is  most  desirable.  One-half 
a  pint  of  cottonseed  oil  (a  cupful),  warmed  to  the  temperature  of  the 
body  by  setting  the  cup  in  warm  water,  is  poured  into  the  irrigator, 
the  rectal  tube  inserted  to  the  length  of  about  4  inches,  and  the 
oil  allowed  to  flow  slowly  into  the  rectum.  It  is  best  taken  at  bed- 
time in  a  recumbent  position,  and  sometimes  it  is  necessary  to  make 
a  preliminary  emptying  of  the  rectum  with  a  small  water  injection, 
so  that  the  oil  may  be  retained,  as  it  should  be,  all  night ;  in  the  morn- 
ing, either  spontaneously,  or  sometimes  with  the  aid  of  a  small  water 
injection,  a  copious  stool  occurs..  At  times,  too,  one  must  confess, 
the  oil  simply  returns  without  any  fecal  matter,  but  it  has  been  my 
belief  under  these  circumstances  that  the  rectal  tube  did  not  enter 
the  intestine  to  sufficient  length.  When  effective,  the  benefit  of  the 
oil  clyster  is  soon  recognized  by  patients,  who  state  that  their  gas 
pains  and  distention  are  benefited,  and  the  stool,  instead  of  being 
as  hard  as  a  stone  (as  they  express  it),  has  become  soft.  The  fear  of 
the  patient  that  the  oil  will  be  passed  involuntarily  during  the  night 
is  rarely  justified,  but,  for  precaution 's  sake,  a  napkin  or  rubber  sheet 
for  the  bed  may  be  employed.  The  treatment  should  be  given  nightly 
at  first  for  a  week,  after  which  twice  a  week  suffices.  Always  specify 
the  kind  of  oil,  particularly  in  clinics  where  the  ignorant  congregate. 
An  unguarded  direction  of  mine  for  any  "good  oil"  brought  from  the 
patient  loud  complaints  of  burning  in  the  rectum,  and  inquiries  dis- 
closed that  any  "good  oil"  had  been  interpreted  by  her  as  meaning 
mineral  machine  oil.  The  indications  for  the  oil  treatment  are  con- 
stipation, mucous  colitis,  peritoneal  adhesions,  and  the  attacks  of 
pain  accompanying  them.  Inoperable  cancer  of  the  rectum  also  can 
be  very  favorably  influenced  by  this  management,  and  stools  induced 
for  a  long  time  when  the  use  of  laxatives  cause  much  pain.  In 
cholelithiasis,  too,  it"  has  seemed  to  me  that  benefit  has  been  derived 
in  lessening  the  severity  and  frequency  of  the  attacks  of  pain  where 
operation  was  inadvisable  or  refused  by  the  patient. 

Perhaps  a  word  or  two  more  in  regard  to  the  apparatus  may  not  be 
amiss.  The  soft  rectal  tube  should  have  two  side  openings,  but  none 
in  the  end,  as  is  common,  because  the  sharp  edges  of  the  end  opening 
will  sometimes  shave  off  a  fragment  of  mucous  membrane,  which  the 


TREATMENT   OF   DIGESTIVE  DISORDERS  257 

other  form  (in  reality  a  miniature  stomach  tube)  cannot  do.  It 
is  useless  to  attempt  to  introduce  the  tube  more  than  10-15  cm,  (4  to 
6  inches),  because  if  passed  beyond  that  point  it  doubles  on  itself 
when  it  reaches  the  sigmoid  and  fluid  will  not  flow  through  it.  The 
"high"  colon  washings  are  merely  delusions  of  the  practitioner,  be- 
cause it  is  impossible  to  pass  a  soft  tube  higher,  and  a  hard  tube  should 
never  be  used  except  under  the  guidance  of  the  eye  (rectoromano- 
seope).  Passing  the  tube  beyond  this  point  is  not  necessary,  how- 
ever, for  in  the  left  prone  position,  with  a  cushion  or  pillow  under  the 
hips,  or  even  purely  horizontal,  the  fluid  will  in  five  minutes  reach 
the  cecum,  as  has  been  the  result  of  my  observation  with  buttermilk- 
bismuth  carbonate  and  the  fluoroscope.  The  hard  rubber  tips  should 
never  be  used,  and  piston  syringes,  except  for  nutriment  or  medicinal 
agents,  are  entirely  uncalled  for.  A  well-worn  precaution,  but  one 
often  neglected,  is  to  open  the  pinch  cock  and  allow  the  air  in  the 
apparatus  to  escape  before  inserting  the  rectal  tube,  which  at  the  same 
time  warms  the  latter.  The  best  lubricant  for  the  tube  is  not  fatty 
substances,  which  are  difficult  to  remove,  but  the  various  preparations 
of  boroglyceride  on  the  market  in  convenient  collapsible  tubes.  The 
amount  of  fluid  employed  is  best  limited  to  500  e.c,  should  be  in- 
troduced very  slowly,  and  retained  as  long  as  possible  for  evacuation 
of  the  lower  colon.  With  persons  possessing  very  lively  reflexes  it 
is  often  well  to  begin  with  smaller  quantities,  a  cupful,  and  then  per- 
suade them  to  increase  the  quantity,  or  the  rapid  defecation  will  utterly 
fail  to  accomplish  the  purpose  for  which  the  injection  was  intended. 

TREATMENT  OF  INTESTINAL  DISEASES. 

The  treatment  of  intestinal  diseases  by  means  of  colon  irrigation 
incidentally  carries  with  it  a  diagnostic  feature,  because  it  is  only 
when  mucus,  blood,  and  pus  are  present  in  the  returning  water  that 
such  treatment  is  worthy  of  continuance.  Where  the  washings  are 
conducted  by  the  physician  or  the  nurse,  it  is  best  to  use  a  funnel, 
which  can  be  raised  or  lowered,  as  described  in  washing  out  the  stom- 
ach, and  the  water  in  portions  of  not  over  350  e.c.  should  be  allowed  to 
flow  in  and  out  until  freighted  with  a  goodly  supply  of  the  path- 
ological product,  when  the  first  portion  may  be  poured  into  a  clean 
glass  for  further  examination  (epithelial  cells,  pus,  etc.)  ;  then  the 
washing  should  be  continued  until  the  fluid  remains  clear.  Under 
normal  conditions  the  first  water  flows  out  clear  or  with  small  fecal 
fragments.     On  account  of  the  difficulty  in  cleaning  rubber  tubes,  the 


258  DISEASES   OF    THE   DIGESTIVE   TRACT 

possible  entrance  of  air,  and  the  danger  of  infection,  double-current 
glass  tubes  have  been  devised,  which  are  so  inexpensive  that  one  can 
be  used  for  each  patient.  It  is  never  advisable,  however,  to  let  the 
patient  have  one  to  use  himself  for  fear  of  breaking  it  by  his  awk- 
wardness. Such  a  one  as  devised  by  Zweig  is  shown  in  Fig.  68, 
but  it  does  not  differ  any  from  various  others  found  in  the  catalogues 
of  instrument  makers.  When  it  is  desirable  for  the  patient  to  use 
such  an  apparatus  himself,  it  should  always  be  made  of  rubber,  and 
should,  of  course,  be  attached  to  a  fountain  syringe,  or  some  other 
reservoir,  instead  of  the  funnel.  The  patient,  on  his  left  side,  has 
the  well-lubricated  rectal  tube  introduced,  with  the  outlet  connected 
to  a  short  piece  of  rubber  tube,  which  directs  the  outflow  of  water 
into  a  basin  or  pail,   while  the  practitioner  pours  a  half  liter  of 


Fig.  68. — Double  current  rectal  tube,     a,  and  b,  ingress;  c,  exit  of  fluid. 

water  into  the  funnel;  or,  if  the  patient  takes  the  treatment  himself, 
the  bag  or  reservoir  may  be  filled  and  the  flow  regulated  by  pinching 
the  tube,  and  the  patient  may  be  seated  over  the  receptacle.  In 
this  way  3  or  4  liters  of  water  may  be  passed  through  the  rectum, 
washing  out  mucus,  fecal  particles,  etc.,  without  any  harm  from  the 
glass  rectal  tube  if  carefully  handled.  If  it  is  desirable  to  have  the 
water  pass  higher  and  wash  out  the  sigmoid,  we  have  only  to  put  a 
clamp  on  the  outlet  tube,  and  after  a  considerable  amount  has  flowed 
in  we  simply  open  the  cock  and  let  the  water  gush  out.  This,  too,  is 
preferable  when  medicaments  are  added  to  the  water;  the  latter  may 
be  employed  for  antiseptic  purposes  or  to  dissolve  mucus.  The  best 
antiseptic  material  is  boric  acid,  sodium  salicylate,  or  thymol,  in  pro- 


TREATMENT   OF   DIGESTIVE   DISORDERS  259 

portion  of  a  teaspoonful  to  a  quart  of  water,  while  for  the  solution 
of  mucus  one  can  add  Carlsbad  salts,  lime  water,  sodium  bicarbonate, 
or  acetate — a  dessertspoonful  to  a  liter  (quart). 

CONTINUOUS  IRRIGATION. 

Continuous  irrigation  of  the  colon  has  been  adopted  by  surgeons 
after  operations  where  much  blood  has  been  lost  or  shock  intervenes, 
as  well  as  by  physicians  where  there  is  great  loss  of  fluid  by  vomit- 
ing or  blood  by  rupture  or  erosion  of  arteries.  A  physiologic  sodium 
chloride  solution  (7:1,000)  is  employed,  which  is  allowed  to  drop  from 
the  reservoir,  regulated  by  a  clamp,  which  contains  a  screw  to  control 
the  pressure.  Ordinarily  a  bulb,  with  a  fine  tube  entering  from  the 
top,  is  interposed,  so  that  one  can  see  at  a  glance  whether  fluid  is  en- 
tering and  how  rapidly. 

NUTRIENT  ENEMATA. 

Nutrient  enemata  are  demanded  usually  by  some  disease  of  the 
digestive  tract.  Among  those  gastric  diseases  where  they  are  most 
stringently  demanded  are  stenoses  of  the  cardia  and  pylorus,  ulcer, 
nervous  vomiting,  and  gastric  crises.  By  this  method  of  feeding  we 
accomplish  one  of  two  purposes — either  maintain  life  when  food  can- 
not enter  or  leave  the  stomach  and  starvation  threatens,  or  we  spare 
the  diseased  organ  until  healing  has  taken  place.  Especially  is  this 
method  valuable  in  chronic  recurring  ulcer,  for  the  pain  and  vomiting 
usually  cease  as  soon  as  the  patient  is  placed  in  bed  and  fed  by 
rectum  for  a  week  or  ten  days,  when  return  to  feeding  by  the  mouth 
may  be  attempted.  After  a  sharp  hemorrhage  from  the  stomach, 
rectal  feeding  must  continue  five  days  at  least  before  resort  to  feed- 
ing by  the  mouth  is  attempted.  Often,  when  pyloric  stenosis  of  benign 
character  exists,  the  patient  can  be  fed  with  great  advantage  for 
eight  to  ten  days,  by  which  the  gastric  fermentation  and  distention 
cease  for  want  of  material,  the  thirst  diminishes,  the  urine  is  in- 
creased, and  often  an  accession  of  weight  may  be  attained  as  a  result 
of  the  decreasing  dilatation.  On  the  contrary,  when  an  operable 
cancer  of  the  tract  exists,  rectal  feeding  should  never  be  employed 
in  the  vain  hope  of  improving  the  condition  of  the  patient  for  opera- 
tion. Those  fed  by  rectum  are  always  undernourished,  and  this  fact, 
together  with  the  wasting,  characteristic  of  the  disease,  makes  a  prob- 
lem of  the  time  of  restoration  to  an  operable  condition.  Operate  at 
once,  and  even  then,  sad  to  relate,  we  have  often  outstayed  the  "ac- 


260  DISEASES  OF   THE  DIGESTIVE   TRACT 

cepted  time."    AYhen  it  has  been  decided  that  the  cancer  is  inoper- 
able, then  we  may  employ  our  nutrient  enema — not  particularly  with 
the  intention  of  prolonging  life,  for  the  condition  of  the  patient  is 
so  miserable  that  this  is  not  to  be  hoped  for,  but  as  a  species  of 
euthanasia,  because  the  sense  of  hunger  is  somewhat  dulled.     Just  as 
in  nourishment  per  os  we  attempt  to  select  a  balanced  ration  con- 
sisting of  fat,  protein,  and  carbohydrates,  so  in  rectal  feeding  we 
select  the  same  ingredients.     The  protein  should,  however,  be  predi- 
gested,  but  not  beyond  the  stage  of  peptone,  for  its  absorption  takes 
place  before  the  active  putrefactive  process  begins,  as  it  will  with 
native  albumens  {egg,  milk,  and  beef  juice).     We  cannot,  however, 
use  more  than  60  grams  (2  ounces)  in  this  way  without  irritating  the 
mucous  membrane  of  the  rectum,  when  it  becomes  intolerant  of  any 
fluid.     The  use  of  the  predigested  casein  preparations  for  this  purpose 
is  to  be  avoided  because  their  absorption  is  extremely  slow.     Raw 
beaten  eggs  are  particularly  well  adapted  for  a  short  time,  and  then 
their  absorption  can  be  hastened  by  the  use  of  cooking  salt  (a  gram 
to  an  egg),  but,  as  the  absorption  is  slow,  as  soon  as  the  dejections 
show  the  offensive  odor  of  putrefactive  products  a  change  must  be 
made  to  some  other  form  of  nutritive  agent,  or  diphtheritic  proctitis 
may  be  set  up.     In  the  meantime  the  rectum  must  be  washed  out  mth 
water  containing  boric  or  salicylic  acid.     The  carbohydrate  can  be 
employed  in  the  form  of  starch,  which  becomes  converted  very  slowly 
to  sugars  by  the  diastase  of  the  succus  entericus  and  by  the  bacteria ; 
but,  as  this  process  is  a  long  one,  it  is  better  to  use  a  partially  dextrin- 
ized  food,  like  many  of  the  children's  foods  on  the  market,  or  even 
sugar  itself,  remembering  that  not  more  than  10  per  cent  may  be 
added  without  the  liability  of  causing  diarrhea.     Unfortunately,  fat 
is  wholly  unsuited  for  rectal  feeding;  it  is  not  digested,  and  practi- 
cally none  of  it  is  ordinarily  absorbed,  as  one  can  easily  convince  him- 
self who  takes  the  trouble  to  examine  a  stool  after  a  nutrient  enema. 
"When,  however,  chopped  pancreas  is  added  to  the  enema,  as  much 
as  20-50  grams  of  fat  can  sometimes  be  brought  to  absorption  through 
the  activity  of  the  digestive  enzyme  in  the  former.     The  various  pan- 
creatic extracts  do  not  contain  steapsin,  and  are  of  no  value  for  this 
purpose.     The  vehicle  for  the  transport  of  these  materials  is  milk, 
which  is  generally  well  utilized  in  the  rectum,  but  the  amount  must 
not  exceed  250  c.c.     Naturally,  with  such  a  wide  range  of  ingredients, 
considerable  ingenuity  has  been  expended  in  devising  nutrient  enema, 
each  of  which  carries  the  name  of  its  originator.     Three  of  the  more 
popular  formulas  are  given : 


TREATMENT   OP   DIGESTIVE  DISORDERS  261 


BIAL — ^VOX    MEHKING. 


Dried  peptone    (Witte)    25  grams 

Saccharum   lactis    25  grams 

Tincturi   opii    10  gtt. 

Water  200  c.c. 


250  grams   milk    

2  egg  yolks 

Pinch  of  salt   

1   tablespoonful  red  wine   

1  tablespoonful   predigested   carbohydrate,   like  Mellin's 
Food 


^300  calories 


2  eggs ^ 

Pinch  of  Mellin's  Food | 

100  c.c.  20  per  cent  grape  sugar  solution ^275  calories 

1  wineglassful  red  wine    

1  teaspoonful  Witte's  peptone   J 

It  can  be  readily  seen  that  even  if  four  such  injections  can  be  given 
daily,  and  they  are  wholly  absorbed,  not  more  than  1,200  calories  can 
be  imparted  in  this  way,  but  it  is  a  fact  that  absorption  under  these 
circumstances  is  very  faulty,  and  is  increasingly  diminished  the  longer 
such  feeding  is  carried  out,  so  that  this  method  of  nourishment  must 
necessarily  soon  reach  an  end  and  can  be  used  only  for  emergencies, 
both  on  account  of  the  undernutrition  and  the  intolerance  of  the 
rectum.  As  an  adjuvant  to  feeding  by  the  mouth,  however,  where 
the  stomach  will  tolerate  only  small  quantities  of  food,  the  nutrient 
enemas  are  very  valuable.  As  to  the  method  of  carrying  out  rectal 
feeding,  it  should  be  done  only  by  a  nurse  fully  acquainted  with  the 
process.  The  apparatus  may  be  the  same  as  suggested  for  colon  wash- 
ing with  rectal  tube  and  funnel,  and  the  rate  of  flow  may  be  easily 
regulated  by  the  height  of  the  latter.  The  rectum,  if  filled  with  feces, 
should  always  be  prepared  at  first  by  an  evacuating  clyster,  repeated 
once  only  daily,  and  to  the  nutrient  enema  10-15  drops  of  laudanum 
must  be  added  to  check  peristalsis.  The  apparatus  must  be  washed 
out  with  warm  water  and  the  fluid  warmied  to  body  temperature,  or 
the  cold,  striking  the  rectum,  will  cause  its  speedy  ejection.  After 
each  nutrient  enema  the  apparatus  must  be  washed  out  with  soap  and 
water,  with  a  little  washing  soda  added,  for  any  fermenting  residue 
clinging  to  the  funnel  or  tube  may  cause  irritation  of  the  intestine 
when  introduced  into  it. 


262  DISEASES   OF   THE   DIGESTIVE   TRACT 

MEDICINAL  TREATMENT 

Medicinal  treatment,  in  spite  of  its  former  popularity  for  digestive 
disorders,  may  be  limited  to  a  very  few  agents ;  four  purposes  we  have 
in  view  to  accomplish :  ( 1 )  to  increase  or  restore  the  hydrochloric  acid 
of  the  stomach  when  deficient  or  absent,  and  incidentally  to  stimulate 
the  pancreas,  which  is  apparently  also  in  a  state  of  lethargy  under 
these  conditions;  (2)  to  neutralize  the  excess  of  mineral  acid  and  to 
restrict  the  exaggeration  of  gastric  secretion  when  the  glands  are  over- 
stimulated;  (3)  to  improve  motility  when  impaired,  for  which  it  is  gen- 
erally conceded  no  drug  has  any  specific  action ;  (4)  to  check  fermenta- 
tion or  even  putrefaction  in  the  stomach  and  intestine;  (5)  to  check 
pain;  (6)  to  regulate  the  movements  of  the  bowels. 

Acids  have  been  employed  ever  since  the  normal  acidity  of  the  gas- 
tric juice  was  found  to  be  due  to  a  mineral  acid,  and  of  these  the 
officinal  dilute  hydrochloric  acid  (10  per  cent)  has  been  most  em- 
ployed, though  dilute  nitromuriatic  still  has  its  adherents.  Of  course 
one  must  first,  by  analysis  of  the  gastric  contents,  be  assured  that  this 
acid  is  diminished  or  absent  in  the  same.  We  cannot  hope  to  replace 
the  amount  usually  secreted  by  the  stomach,  for  one  meal  would  re- 
quire 320  drops  of  the  dilute  acid  to  produce  a  2 :1,000  solution  of  the 
absolute  acid,  such  as  is  found  ordinarily  in  a  gastric  content,  an 
amount  impossible  of  ingestion.  Furthermore,  it  would  require  100 
drops  of  the  officinal  dilute  acid  to  digest  2  eggs,  so  that  it  is  evident 
how  puny  our  efforts  are  to  replace  the  normal  acid  of  the  stom- 
ach; hence  our  hopes  rest  on  stimulating  the  secretion  of  hydro- 
chloric acid,  and  incidentally,  of  course,  of  gastric  juice,  for  it  has 
been  well  established  that  deficient  acid  means  impaired  secretion  of 
the  digesting  fluid,  and,  in  fact,  experiment  demonstrates  that  this 
result  follows  the  ingestion  of  the  officinal  product.  Bickel,  for  in- 
stance, showed  in  a  dog  which  possessed  the  small  stomach  as  a  result 
of  Pawlow's  operation,  and  was  suffering  from  gastritis  and  absence 
of  hydrochloric  acid,  that  when  milk  alone  was  given  it  to  drink,  no 
acid  appeared  in  the  small  stomach,  but,  if  7.3  c.c.  of  our  officinal  acid 
in  200  c.c.  of  water  was  poured  into  the  larger  stomach  and  an  hour 
later  200  c.c.  of  milk  was  poured  in,  the  smaller  stomach  not  only 
contained  hydrochloric  acid  then,  but  for  hours  later,  though,  of 
course,  no  communication  could  occur  between  the  divisions  of  the 
stomach.  Bickel  also  showed  that  the  secretion  of  acid  by  the  dis- 
eased stomach  was  unaffected  if  officinal  acid  was  given  during  diges- 
tion, but  the  stomach  promptly  responded  with  its  secretion  if  the 


TREATMENT   OF   DIGESTIVE   DISORDERS  263 

medicinal  agent  was  given  before  the  animal  begins  to  eat.  It  is 
sometimes  curious  to  note  that  patients  declare  that  great  relief  has 
been  obtained  from  the  medicinal  use  of  hydrochloric  acid  when  re- 
peated examinations  of  the  gastric  contents  fail  to  show  any  return 
of  it  to  the  secretion.  In  addition,  hydrochloric  acid  is  supposed  to 
stimulate  the  secretion  of  enzymes,  and  in  cases  of  achylia  where  both 
rennin  and  pepsin  M^ere  absent  they  have  been  restored  by  giving 
hydrochloric  acid  (^Minkowski).  Another  activity  already  mentioned 
of  the  acid  is  the  stimulation  of  an  active  pancreatic  juice,  and 
Glaessner  actually  reports  that  in  a  woman  with  a  pancreatic  fistula 
he  could  double  the  amount  and  activity  of  the  pancreatic  juice,  by 
giving  hydrochloric  acid.  It  is  still  a  question  whether  hydrochloric 
acid  exerts  any  antifermentative  or  antiseptic  action  in  the  "stomach 
on  account  of  the  state  of  extreme  dilution  which  it  must  assume  there, 
but  in  cases  of  anorexia  it  often  arouses  the  appetite,  like  one  of  the 
bitters.  On  the  contrary,  a  mineral  acid  should  never  be  used  when 
there  is  an  excess  of  hydrochloric  acid  in  the  stomach.  There  are 
many  ways  in  which  hydrochloric  acid  may  be  given,  but  my  prefer- 
ence is  to  add  10-15  drops  of  the  officinal  dilute  to  a  glass  of  water,  of 
which  half  is  to  be  taken  through  a  drinking  tube  before  the  meal  and 
the  other  half  after  it.  For  those  who  cannot  carry  the  fluid  about, 
or  who  dislike  the  taste  of  the  acid,  acidol  (betain  hydrochloride)  in 
half-gram  tablets,  each  containing  4  to  5  drops  of  the  free  acid,  is  an  ad- 
mirable substitute,  but  it  is  expensive.  One  or  two  are  to  be  dis- 
solved in  a  wineglass  of  water  and  taken  directly  after  meals.  The 
solution  is  pleasant  to  take,  does  not  injure  the  teeth  if  taken  directly 
after  dissolved,  and  the  free  acid  is  gradually  liberated  in  the  stomach. 
The  tablets  should  not  be  swallowed  undissolved  because  of  local  irri- 
tation. These  tablets  are  also  provided  with  the  addition  of  pepsin 
(acidol  pepsin),  but  in  my  experience  they  are  no  more  effective  than 
those  containing  the  hydrochloric  acid  alone.  They  are  put  up  in 
tubes  of  10  tablets  each,  so  that,  by  prescribing  for  10  or  multiples  of 
10,  one  obtains  unbroken  containers.  Another  excellent  combination 
where  hypotony  exists  coincidentally  with  achlorhydria  is  a  mixture  of 
equal  parts  of  tincture  of  nux  vomica  and  dilute  hydrochloric  acid,  of 
which  15  to  20  drops  are  to  be  taken  in  a  glass  of  water  under  the  same 
conditions  as  the  acid  alone. 

Alkalies  have  been  employed  for  ages  medicinally  without  any  una- 
nimity of  opinion  among  investigators  as  to  their  effect  beyond  the 
immediate  neutralization  of  the  acid  present,  be  it  mineral  from  hyper- 
secretion or  organic  from   fermentation,   in  the  stomach.     In   small 


264  DISEASES  OF   THE   DIGESTIVE   TRACT 

doses,  though  a  portion  of  the  hydrochloric  acid  is  neutralized,  this  is 
followed,  some  say,  by  an  increased  secretion  of  gastric  juice.  Large 
doses  diminish  the  secretion,  and  it  is  generally  conceded  that  long  em- 
ployment of  Carlsbad  salts  diminishes  the  hydrochloric  acid  and  the 
pepsin  (gastric  secretion).  Bickel,  with  his  gastrostomized  dogs, 
found  that,  when  an  alkali  was  placed  in  the  larger  stomach,  the 
smaller  failed  to  secrete  an  acid  gastric  juice,  though  there  was  no 
contact,  even  when  pilocarpine  was  injected,  which  ordinarily  produces 
a  free  flow  of  acid-containing  gastric  juice.  The  experimental  results 
may,  however,  be  determined.  Clinically  we  know  that  persons  suf- 
fering from  hypersecretion  are  benefited  temporarily  by  the  use  of 
alkali,  and  there  is  no  reason  to  believe  that  there  are  any  unfavorable 
secondary  results.  The  alkali  should  always  be  given  one  or  two 
hours  after  the  meal,  the  period  of  highest  acidity,  and  not  before  or 
directly  After  meals.  The  existence  of  the  hypersecretion  must  always 
be  determined  by  the  examination  of  gastric  contents.  Ordinarily  the 
time  at  which  the  alkali  is  to  be  taken  can  be  left  with  the  patient, 
who  can  usually  tell  with  fair  accuracy  when  his  "burning  pain," 
as  he  calls  it,  begins,  and  the  alkali  should  precede  this  by  a  few 
minutes.  When,  as  sometimes  happens,  there  is  a  continuous  secretion, 
the  patient  is  aroused  in  the  early  morning  hours  by  the  pain,  and  a 
dose  of  alkali  prepared  and  placed  at  his  bedside  the  night  before, 
after  being  taken,  will  enable  him  to  finish  his  night's  rest.  It  is  a 
generally  entertained  opinion  among  the  laity  that  continuous  use  of 
sodium  bicarbonate,  or  saleratus,  is  harmful — "eats  out"  the  lining 
of  the  stomach,  as  they  express  it — but  when  used  solely  for  hyperse- 
cretion and  not  for  every  discomfort  of  which  the  digestive  organs 
may  be  guilty,  there  can  be  no  harm  in  its  use,  though  it  is  rarely  a 
constituent  of  my  prescriptions  for  reasons  stated  later.  It  is  very 
difficult  to  make  the  "punishment  fit  the  crime" — in  other  words,  to 
gauge  the  amount  of  alkali  to  be  given  by  the  amount  of  hydrochloric 
acid  in  the  gastric  contents,  for  some  individuals  with  an  excessive 
acidity  will  complain  but  little,  while  others  with  but  slight  increase, 
or  even  an  acidity  below  normal,  will  complain  bitterly  of  "heart- 
burn. ' '  Zweig  suggests  in  these  latter  cases  that  the  secretion  is  very 
rapid  for  a  short  period  after  food  is  taken,  but  the  high  acidity  is 
diminished  by  the  dilution  of  the  alkaline  fluid,  so  that  at  the  end  of 
an  hour  (the  usual  period  of  removal)  the  acidity  is  not  above  normal 
(concealed  hypersecretion),  and  in  such  cases  recommends  that  the 
alkali  be  given  directly  after  meals.  Two  groups  of  alkalis  have  won 
the  favor  of  the  medical  profession — the  carbonates  of  the  simple  alka- 


TREATMENT   OF   DIGESTIVE   DISORDERS  265 

lies,  like  sodium  bicarbonate  or  carbonate,  and  the  heavier  metal,  mag- 
nesium as  an  oxide,  usually  calcined,  to  form  the  finer  product.  AVhen 
brought  in  contact  with  hydrochloric  acid,  the  latter  is  found  to  bind 
or  neutralize  four  times  as  much,  weight  for  weight,  as  the  former.  It 
is  bulky,  however,  and  not  so  pleasant  to  take,  except  as  the  milk  of  mag- 
nesia or  magma  magnesias  of  the  Newer  Formulary,  containing  5  per 
cent  of  magnesium  hydroxide  or  half  a  gram  (T^/o  grains)  in  every  des- 
sertspoonful. The  amount  of  alkali  to  be  given  varies  roughly  as  the 
total  acidity  of  the  gastric  content.  If  as  high  as  80,  8-10  grams  of  so- 
dium bicarbonate  or  2  to  3  grams  of  magnesium  oxide  should  be  given 
three  times  daily,  to  neutralize,  theoretically,  the  acid  of  the  stomach ; 
but,  as  complete  neutralization  is  not  desired,  and  only  such  a  reduction 
that  the  patient  is  free  from  discomfort,  in  my  experience  %  to  1  gram, 
or  10  to  20  c.c,  of  the  milk  of  magensia,  are  sufficient.  "Where  atony  or 
muscular  insufficiency  of  the  stomach  exists,  the  bicarbonates  are  much 
less  desirable,  because  the  carbon  dioxide,  set  free,  still  further  dis- 
tends the  weakened  organ.  The  artificial  Carlsbad  salts  also  serve  ad- 
mirably for  hypersecretion,  given  in  doses  of  14  teaspoonful  in  a  half 
cup  of  hot  water  on  rising  and  an  hour  or  two  before  the  evening 
meal.     ]\Iy  favorite  prescription,  however,  is  as  follows : 

IJ     Atropinse  sulphatis   0.010  or  1^  grain 

Magmatis  magnesiae,  N.F 240.0       or  8  ounces 

M.  Sig. :     Dessert-spoonful  a  half -hour  after  meals. 

With  this  mixture  it  has  usually  been  possible  to  free  the  patient 
from  the  "heartburn"  of  hypersecretion.  If  there  are  accessions  at 
times,  he  is  simply  required  to  scrape  off  from  a  cake  of  magnesia,  sus- 
pend in  water,  and  drink  enough  to  check  the  increased  acidity. 
Sodium  citrate,  which  was  a  favorite  with  Boas  for  this  purpose,  is 
said  to  subsequently  stimulate  gastric  secretion  and  has  fallen  more  or 
less  into  disrepute. 

Bitters  and  stomachics  are,  perhaps,  the  most  ancient  of  our  reme- 
dies, for  even  to  our  forefathers  the  principle  scientifically  established 
by  Pawlow  was  known — that  you  must  arouse  appetite  before  you 
could  insure  your  patient  an  efficient  digestion.  Other  than  for  this 
act  of  arousing  appetite,  the  bitters  have  been  shorn  of  their  supposed 
power  to  stimulate  gastric  secretion  per  se,  being  but  little  better  in 
this  respect  than  an  equal  amount  of  cold  water.  At  least  the  active 
influence  of  this  class  of  remedies  on  stimulation  of  gastric  juice,  when 
it  does  occur,  comes  after  the  drug  has  left  the  stomach,  so  that  they 
should  be  given  half  an  hour  to  an  hour  before  food  is  taken.     "With 


266  DISEASES   OF   THE   DIGESTIVE   TRACT 

these  scanty  proofs  of  the  efficacy  of  bitters  in  improving  both  motility 
and  secretion,  we  must  content  ourselves,  and  fall  back  on  the  old  em- 
pirical formula  that  people  improve  in  appetite  and  digestion  on  their 
use.  The  number  of  these  bitters  is  vast,  but  one  can  get  along  with 
the  few  we  have  mentioned,  and  the  others  in  the  group  have  never  ac- 
complished any  result  that  these  could  not  do : 

1.  Nux  vomica  in  the  form  of  the  tincture,  in  10-drop  doses,  fifteen 
to  twenty  minutes  before  mealtime  in  a  wineglass  of  water. 

2.  Gentian  in  the  form  of  the  compound  tincture,  which  also  con- 
tains bitter  orange  peel  and  cardamom,  in  teaspoonful  doses,  well 
diluted,  some  little  time  before  meals.  A  favorite  combination  at  the 
clinic  is  as  follows : 

IJ     Tincturse  nucis  vomicae   10.0  or  3  drams 

Tincturae   gentianae   compositae    50.0  or   1%  ounces 

Elixiris   pepsini,   X.F.,  q.s.   ad 100.0  or  3  ounces 

M.  Sig. :     Teaspoonful  in  water  before  meals. 

3.  Condurango  in  the  form  of  the  fluid  extract,  though  long  since 
having  lost  its  reputation  for  the  cure  of  gastric  cancer,  forms,  in  20- 
to  30-drop  doses,  given  in  water  before  meals,  an  admirable  bitters, 
and  can  usually  be  procured  at  all  apothecaries,  though  the  Pharma- 
copeia has  dropped  it. 

4.  Orexin,  chiefly  used  in  the  form  of  the  tannate,  has  proven  very 
satisfactory  in  my  hands  for  arousing  appetite  and  restoring  the  flow 
of  gastric  juice  in  achylias  of  nervous  origin  and  in  persistent  nausea 
which  often  accompanies  the  same  condition.  It  is  best  given  in 
tablets  of  0.25  grams  each  (4  grains),  which  should  be  crushed  and 
taken  with  a  half  glass  of  water  at  least  an  hour  before  the  meals. 
These  tablets  are  put  up  in  tubes  of  ten  each,  and,  by  ordering  that 
number  or  a  multiple,  original  containers  can  be  obtained.  They  are 
also  sold  by  Merck  under  the  name  of  orexoids,  but  are,  however,  abso- 
lutely contraindicated  in  chronic  gastric  ulcer,  hypersecretion, 
nephritis,  and  in  all  circumstances  where  vomiting  must  be  avoided 
(recovery  from  abdominal  operations). 

5.  Creasote  was  introduced  largely  by  Klemperer  for  hypomotility 
and  failing  appetite.  It  may  be  given  in  capsules  containing  0.05 
gram  (1  grain)  with  milk  sugar  0.3  (5  grains)  each,  or  in  pill  form, 
or  often,  for  its  suggestive  effect,  in  sherry  wine,  as  follows : 

IJ     Creasoti    1.0  or   15  grains 

Vini  xerici  q.s.  ad 100.0  or  3  ounces 

M.  Sig. :     Teaspoonful  in  water  before  meals. 


TREATMENT   OF   DIGESTIVE   DISORDERS  267 

It  is  needless  to  say  that  only  the  beeehwood  creasote  should  be  used 
and  never  the  synthetic. 

Ferments  have  long  been  employed  to  accomplish  digestion  in  the 
stomach  or  intestine,  but,  with  few  exceptions,  have  proven  disappoint- 
ing. At  first  it  was  the  various  diastases  which  were  to  aid  the  diges- 
tion of  starch  where  hypersecretion  was  present,  but,  if  the  examina- 
tion of  the  stool  is  carefully  followed,  little  change  can  be  seen  in  the 
number  of  starch  granules  when  either  ptyalin,  the  various  malt  di- 
astases, or  taka-diastase  is  used ;  in  fact,  it  is  not  at  all  certain  that 
the  increased  gastric  secretion  is  necessarily  the  cause  of  this  loss  of 
starch  to  the  body. 

Pepsin,  too,  has  had  its  vogue,  but  at  present  we  realize  that  indi- 
cations for  its  use  grow  less  and  less.  If  hydrochloric  acid  is  present, 
we  always  find  pepsin;  if  absent,  then  pepsin  is  often  present  as  a 
mother  substance,  to  be  promptly  activated  by  large  doses  of  hydro- 
chloric acid.  One  manufacturing  house  has  made  a  fortune  out  of 
such  preparations  as  a  combination  of  pancreatin  and  pepsin,  not 
realizing,  as  the  Scriptures  have  it,  that  the  ' '  Lean  kine  will  eat  up  the 
fat  kine, ' '  or,  in  other  words,  that  trypsin  is  destroyed  by  the  pepsin- 
hydrochloric  acid  of  the  stomach.  Another  favorite  preparation  was 
wine  of  pepsin,  of  which  the  alcohol  would  promptly  stay  the  hand  of 
the  pepsin  if  it  were  at  all  active ;  yet,  such  is  the  force  of  old  associa- 
tions and  former  beliefs,  that  two  preparations  still  form  a  part  of  my 
armamentarium — elixir  pepsini  used  largely  as  an  elegant  excipient, 
and  acidol-pepsin — in  both  of  which  preparations  there  is,  in  my  mind, 
not  the  slightest  expectation  that  the  pepsin  adds  to  the  efiicacy  of 
either. 

Pancreatin  and  panJcreon  are  also  frequently  used  without,  accord- 
ing to  my  observation,  accomplishing  much  when  the  control  is  the  ex- 
amination of  the  stool  and  not  the  feelings  or  impressions  of  the  pa- 
tient. Both  preparations  are  best  given  in  powder  or  capsule,  for 
the  tablets  often  fail  to  dissolve  in  the  canal  and  are  found  in  the  stool. 
Pankreon,  prepared  by  treatment  of  pancreatin  with  tannic  acid,  is 
said  to  be  impervious  to  the  action  of  gastric  juice  and  to  contain  all 
of  the  ferments  of  the  pancreatic  secretion,  a  statement  not  worthy  of 
full  credence,  for  steapsin  is  a  most  elusive  enzyme  and  is  usually  de- 
stroyed or  lost  in  a  fresh  extract  of  pancreas  in  a  short  time.  Yet 
there  can  be  no  doubt  that  the  diarrhea  which  follows  achylias  is  very 
much  benefited  by  pankreon,  while  the  amount  of  connective  tissue  and 
meat  fibers  in  the  stool  diminishes,  and  there  is  undoubted  evidence 
that  the  utilization  of  fat  in  pancreatic  disease  improves  under  its 


268  DISEASES   OF   THE   DIGESTIVE   TRACT 

use ;  in  fact,  some  would  make  this  improved  absorption  of  fat  after  its 
ingestion  the  means  of  diagnosing  an  impaired  pancreas.  It  is  best 
given  in  capsules  in  doses  of  0.3-0.5  gram  (5-7i/^  grains)  just  before 
meals.  In  clinics,  where  such  preparations  are  not  available  on  ac- 
count of  their  cost,  pancreatin  in  similar  doses  may  be  used  in  keratin- 
covered  pills. 

Papain  and  papayotin,  both  derived  from  the  sap  of  the  carica 
papaya,  have  been  employed  by  many  and  recommended  by  some,  while 
others  disclaim  any  therapeutic  value  for  them,  yet  both  are  chemi- 
cally alike  and  form  a  whitish-yellow  powder,  soluble  in  water  which 
has  been  rendered  slightly  alkaline  or  acid.  It  is  evident  that  it  will 
digest  raw  egg  albumin,  or  fibrin  in  neutral  and  slightly  alkaline  solu- 
tion, nor  is  this  action  stayed  by  slightly  acid  reaction,  but  on  cooked 
egg  or  meat  it  has  little  or  no  effect ;  hence  it  can  never  form  a  substi- 
tute for  the  pepsin  of  an  active  digestion.  It  is  recommended  in 
chronic  gastritis,  gastric  cancer  and  its  accompanying  dilatation,  but 
should  never  be  used  in  hypersecretion  or  gastric  ulcer.  My  expe- 
rience has  been  confined  to  its  employment  in  functional  achylia, 
where,  according  to  the  statements  of  the  patients,  it  benefited  their 
discomfort,  but  examination  of  the  gastric  contents  during  its  use 
never  showed  any  change  in  the  coarse,  undigested  appearance  of  the 
bread.  It  is  to  be  given  as  a  powder,  in  doses  of  0.25-0.5  gram  (4- 
lyo  grains),  suspended  in  a  little  water,  just  after  meals,  and  may  be 
repeated  two  or  three  times  during  the  digestion.  It  can  also  be  pro- 
cured in  tablet  form,  whose  administration  is  much  more  convenient 
and  probably  as  effective. 

Gastric  secretion  can  be  controlled  only  to  a  moderate  degree  by 
therapeutic  agencies.  The  means  for  increasing  secretion  have  already 
been  mentioned  under  acids  and  stomachics,  and  to  that  list  we  can 
add  only  pilocarpine,  which  increases  the  volume  of  the  gastric  juice 
as  well  as  the  pepsin,  but  not  its  hydrochloric  acid  in  proportion. 
There  are  so  many  unpleasant  features,  however,  attached  to  its  use 
(salivation,  perspiration,  etc.)  that  its  employment  for  this  purpose  is 
impracticable.  For  the  diminution  of  gastric  secretion  we  have  only 
belladonna  and  its  alkaloid,  atropine,  or  some  of  the  various  modi- 
fications of  the  latter,  like  the  methylatropine  bromide  or  methylatro- 
pine  nitrate  (eumydrine),  which  apparently  have  the  same  inhibitive 
influence  on  secretion  and  are  much  less  poisonous.  It  has  been  fully 
demonstrated  that  atropine  not  only  diminishes  the  amount  of  gastric 
juice  and  its  acid  without  change  in  the  pepsin  content,  but  also  checks 
the  motility  of  the  stomach ;  hence  it  can  be  seen  that  atropine  possesses 


TREATMENT   OF   DIGESTIVE  DISORDERS  269 

this  advantage  over  alkalies — that  it  does  not  neutralize  the  acid  already 
secreted,  but  checks  such  secretion.  Furthermore,  atropine  stays  the 
tendency  to  cramps,  and  in  general  exercises  a  soothing  influence  on 
the  excitability  of  the  sensory  terminal  nerve  endings  in  the  organ.  It 
is  employed  to  best  advantage  in  hypersecretion,  gastric  ulcer,  pyloric 
spasm — whether  due  to  the  latter,  as  some  claim,  or  to  the  hypersecre- 
tion alone — and  in  spasm  of  the  cardia.  In  addition,  it  can  be  used 
advantageously  in  spasm  of  the  colon,  anal  fissure,  and  ileus  due  to 
bands  and  adhesions  by  relaxing  the  accompanying  contraction  which 
causes  stenosis;  in  fact,  in  some  cases  in  which  an  operation  appeared 
to  be  the  only  means  of  relief  the  stenosis  has  been  overcome  by  hypo- 
dermic injections  of  0.001  gram  (%o  grain)  of  atropine  sulphate.  As  a 
continuous  means  of  treatment,  atropine  sulphate  may  be  given  in 
doses  of  0.0005-0.001  gram  (^20-^60  grain),  either  in  tablets  or,  in 
conjunction  with  an  alkali,  magnesia,  or  sodium  bicarbonate,  as  a 
powder  just  before  meals.  The  custom  of  the  German  school  to  direct 
that  such  a  mixture  be  dispensed  in  bulk  to  the  patient,  to  be  given  in 
doses  as  large  as  can  be  taken  up  on  the  end  of  a  knife,  is  not  safe, 
and  the  powder  should  always  be  divided  into  the  required  doses  by 
the  druggist.  The  extract  of  belladonna  may  be  given  in  doses  of  0.02- 
0.03  gram  {Yg-}^  grain),  either  with  the  alkali  as  a  powder  or,  bet- 
ter still,  in  the  form  of  a  suppository,  which  may  be  employed  at  bed- 
time, while  the  alkali  is  given  during  the  day.  Methylatropine  nitrate 
(eumydrine)  forms  an  admirable  substitute  for  atropine,  as  stated, 
and  can  be  given  in  1-  or  2-mgm.  doses,  either  alone  in  pills  or  drops, 
.or  added  to  alkaline  powders  or  to  milk  of  magnesia  or  bismuth, 
since  it  is  often  given  to  allay  hypersecretion,  which  the  alkalies  only 
temporarily  relieve.  The  disadvantages  of  atropine  are  the  peculiar 
susceptibility  or  idiosyncrasies  manifested  by  some  persons  even  when 
it  is  given  in  perfectly  safe  doses,  which  consist  of  dry  throat,  delirious 
fancies,  flushing,  and  sometimes  erythema,  all  of  which  can  be  avoided 
by  the  use  of  eumydrine.  The  disadvantage  of  the  latter  is  the  in- 
ability to  procure  it,  as  many  druggists  do  not  carry  it.  Only  very 
rarely  does  a  patient  ever  complain  of  untoward  symptoms  when 
taking  eumydrine,  a  statement  which  cannot  be  made  of  atropine. 

Sedatives  and  carminatives  play  an  important  part  in  therapeutics 
of  the  digestive  tract,  because  most  of  the  discomfort  complained  of  by 
those  suffering  from  gastric  neurosis  is  the  so-called  "lump  in  the 
throat,"  probably  due  to  spasm  of  the  cardia,  and  the  feeling  of  dis- 
tention after  a  meal,  which  is  not  by  any  means  always  accompanied 
by  physical  signs  of  flatus.     Presumably  the  old  remedies,  tinctura 


270  DISEASES   OF   THE   DIGESTIVE   TRACT 

eardamomi  eomposita,  spiritus  setheris  compositus,  menthol,  and  many- 
others,  are  as  good  as  the  newer  ones,  and  may  be  employed  in  the 
clinics,  where  expense  counts,  but  in  private  practice  validol  (menthol 
ester  of  valerianic  acid  with  30  per  cent  of  free  menthol),  in  10-drop 
doses  on  a  lump  of  sugar  or  in  milk,  since  it  is  not  soluble  in  water, 
taken  three  or  four  times  daily,  forms  a  means  of  overcoming  the  sensa- 
tion of  pressure,  as  well  as  relaxing  the  cardia  with  free  eructations  of 
gas  or  swallowed  air,  whichever  it  may  be.  Morphine  should  never  be 
used  for  this  purpose,  particularly  if  accompanied  by  hypersecretion, 
for,  though  at  first  it  diminishes  secretion,  later  it  always  increases  it. 
Codeine,  however,  either  as  a  sulphate  or  phosphate,  as  a  constituent 
of  powders  for  calming  minor  painful  sensations  in  the  stomach  or 
intestines  may  be  employed,  for  experiment  has  shown  that  it  does  not 
share  the  disagreeable  after-effects  of  morphine.  As  a  means  of  com- 
bating nausea  and  vomiting,  chloroform  water  in  tablespoonful  doses 
often  works  well,  as  does  cocaine  hydrochloride.  A  favorite  pre- 
scription containing  this  is  as  follows : 

R     Cocainae  hydrochloridi   0.3  or  4^  grains 

Aquae  menthae  piperitae   50.0  or  1%  ounces 

Aquae  q.s.  ad   100.0  or  3  ounces 

M.  Sig. :     Teaspoonful  in  water  every  three  hours. 

Resorcinol  also  has  a  favorable  influence  on  nausea,  and  can  be  given 
in  0.2-gram  (3-grain)  doses,  dissolved  in  aromatic  elixir.  The  pain 
associated  with  chronic  ulcer  of  the  stomach  or  duodenum  can  be 
alleviated  by  anesthesin  in  0.2-gram  (3-grain)  doses  in  capsules  taken 
just  before  the  time  of  the  usual  periodic  pain,  as  well  as  an  hour 
after  eating  if  gastric,  and  3  hours  if  duodenal.  However  valuable 
these  sedatives  are  for  relieving  pain,  when  the  disease  is  incurable 
(cancer),  they  should  not  be  used  to  the  exclusion  of  other  remedies  in- 
tended to  cure  the  disease,  for  their  constant  use  hides  its  progress  and 
gives  a  false  sense  of  improvement. 

Laxatives  have  won  such  a  strong  hold  on  the  laitj'  that  it  is  almost 
as  difficult  to  persuade  some  patients  to  give  them  up  as  it  is  the  use 
of  alcohol  or  narcotics.  Every  kind  has  its  adherents,  and  the  so- 
called  ''patented"  articles  sold  through  questionable  announcements 
of  their  advantages  in  the  papers  have  largely  increased  this  evil. 
Apart  from  a  single  dose,  used  at  long  intervals  to  unload  the  colon 
of  its  contents  when  malaise,  furred  tongue,  and  headache  exist,  the 
choice  of  laxatives  should  be  confined  to  the  mildest  that  will  accom- 
plish the  purpose.  These  drugs  act  by  increasing  the  peristalsis,  either 
by  direct  irritation  of  the  intestinal  walls  or  their  ganglia,  or  by  re- 


TREATMENT   OF   DIGESTIVE   DISORDERS  271 

flex  action  from  irritation  of  the  sensory  nerves.  Two  harmful  effects 
follow  their  use — first,  the  intestine  becomes  so  atonic  that  only  the 
most  drastic  agencies  have  any  effect,  and,  second,  actual  pathologic 
conditions,  like  gastric  catarrh,  aehylia,  and  chronic  enteritis,  follow 
their  use.  Furthermore,  their  early  effect  is  often  to  produce  excessive 
hypersecretion  in  the  stomach,  which  cannot  be  checked  until  the  laxa- 
tives are  given  up.  They  are  always  contraindicated  when  any  inflam- 
matory disturbances,  like  appendicitis  or  peritonitis,  exist,  or  when 
spasm  of  the  colon,  lead  colic,  or  acute  ileus  is  present.  The  time  at 
which  the  drug  is  taken  plays  an  important  part  in  its  choice.  If 
salts  are  employed,  like  sodium  or  magnesium  sulphate  or  sodium  phos- 
phate, they  should  be  taken  on  rising,  before  breakfast,  when  in  one  or 
two  hours  there  follows  a  copious  watery  discharge;  if  cascara,  rhu- 
barb, or  the  innumerable  other  pills  and  syrups  which  act  slowly,  they 
should  be  given  at  bedtime,  when  the  stool  follows  the  next  morning, 
A  list  of  all  the  drugs  used  for  this  purpose  would  be  like  that  of  the 
ships  that  came  to  Troy,  but  a  few  which  have  served  me  best  will  be 
mentioned  without  detracting  any  from  the  merit  of  the  numerous 
others : 

1.  Oleum  ricini,  or  castor  oil,  is  to  be  given  only  when  there  is  im- 
mediate need  of  a  thorough  evacuation,  and  not  continually.  A  table- 
spoonful  is  the  usual  dose,  taken  in  coffee,  root  beer,  or  with  lemon 
juice.  At  present  it  can  be  procured  in  capsules  containing  5-15 
grams. 

2.  Fluid  extract  of  cascara  sagrada  can,  in  general,  be  used  with 
the  greatest  safety,  as  it  produces  (in  i/^-  to  1-teaspoonful  doses  at  bed- 
time) a  free  movement,  usually  without  any  griping,  with  less  disturb- 
ance in  the  stomach  than  any  other  of  this  class ;  in  fact,  it  is  recom- 
mended by  some  as  a  stomachic,  to  be  given  in  smaller  doses  before 
meals.  The  unpleasant  taste  of  this  drug  has  been  largely  overcome 
by  most  manufacturing  pharmacists  in  special  preparations,  such  as 
cascara  evacuant  (20-30  drops)  and  cascara  cordial  (1-4  teaspoonfuls 
at  bedtime).  It  can  also  be  obtained  in  the  dry  extract,  of  which  pills 
of  0.25  gram  (4  grains)  are  officinal. 

3.  Aloin,  which  has  always  been  employed  by  us  in  the  form  of 
pilulte  aloini,  strychninfe  et  belladonnae,  as  it  was  formerly  termed,  but 
now  somewhat  modified  by  the  addition  of  ipecac  and  liquorice,  main- 
tained by  the  Pharmacopeia  under  the  name  of  pilulfe  laxativae  com- 
positae.  One  or  two  of  these  at  bedtime  may  be  used  with  compara- 
tive safety  for  a  long  time,  but  gastric  distress  after  eating,  sooner  or 
later,  demonstrates  their  effect  on  the  stomach. 


272  DISEASES   OF   THE   DIGESTIVE   TRACT 

4.  Agar-agar,  introduced  by  A.  Schmidt,  is  a  laxative  only  by  virtue 
of  its  indigestibility  and  insolubility.  It  can  be  procured  in  the  com- 
mercial form  in  strands  or  sticks  and  cooked  by  the  patient  in 
fruit  or  vegetables,  or  some  of  my  patients  carry  it  about  with  them 
and  nibble  it  as  they  would  sweet  flag  or  liquorice.  It  is  also  put  up 
in  the  form  of  crackers,  which  can  be  obtained  at  almost  any  apothe- 
cary. Kegulin,  too,  is  a  very  elegant  preparation  of  agar-agar,  with 
25  per  cent  of  watery  extract  of  cascara,  and  may  be  given  in  1-  to  2- 
teaspoonful  doses,  but,  like  all  our  imported  medicinal  articles,  the 
duty  makes  the  price  beyond  the  means  of  any  but  the  well  condi- 
tioned. 

5.  Liquid  petroleum,  which  has  been  purified  for  internal  use,  also 
has  the  same  effect  as  agar-agar,  being  indigestible  and  unabsorbable 
in  the  digestive  tract.  It  is  given  in  tablespoonful  doses  night  and 
morning.  Ordinarily  it  is  taken  without  any  distaste,  but  rarely  some 
varieties  have  a  slight  odor  of  kerosene,  so  that  it  is  best  to  add  0.5 
gram  of  oil  of  gaultheria  to  each  240  c.c.  (8  ounces). 

6.  Hydrargyrum  chloridum  mite  has  been  undoubtedly  in  former 
ages  the  curse  of  humanity,  and  no  one  will  ever  write  the  history  of 
its  victims,  stomatitis  and  diphtheritic  colitis  following  its  free-hand 
administration,  which  undoubtedly  caused  the  revolt  against  heroic 
dosing  and  made  way  for  the  newer  fads  of  homeopathy,  eclecticism, 
and  Thomsonianism.  As  at  present  administered,  however,  in  doses 
of  0.006  gram  (^4o  grain)  in  tablet  form,  or  with  the  addition  of 
sodium  carbonate,  0.06  gram  (1  grain),  repeated  hourly  for  10  doses, 
it  has  proved  as  effective  for  the  purpose  intended  (especially  if  fol- 
lowed on  the  succeeding  morning  by  a  dose  of  sodium  phosphate  or 
artificial  Carlsbad)  as  the  large  doses  of  the  last  century,  without  any 
of  the  dangers  of  those  quantities.  The  power  of  calomel  to  render 
the  intestinal  canal  aseptic  has  been  largely  overestimated  as  well  as 
its  theoretical  power  to  increase  the  flow  of  bile.  Both  apparent 
actions  are  wholly  dependent  on  the  increased  peristalsis  by  which  un- 
reduced bile  pigment  and  the  putrefying  contents  are  ejected. 

7.  Phenolphthalein,  a  mild  laxative,  in  evening  doses  of  0.1-0.3 
gram  {IVo-B  grains)  is  to  be  recommended  when  continued  use  is 
desired,  but  not  an  immediate  and  effective  clearing  out  of  the  in- 
testine. It  will,  however,  prove  disappointing,  for  it  soon  loses  its  ef- 
fect on  the  sarnie  patient,  and  not  rarely  after  long  use  causes  colon 
catarrh. 

Antidiarrheal  remedies  are  divided  into  three  classes,  according  to 
the  method  of  their  action: 


TREATMENT   OF   DIGESTIVE  DISORDERS  273 

1.  The  first  group  is  that  class  which  dulls  the  nervous  endings  in 
the  intestinal  canal  and  at  the  same  time  arouses  to  activity  the  retard- 
ing filaments  of  the  splanchnic  nerve.  The  best  of  this  group  is  opium, 
but  we  may  add  its  derivatives — morphine,  codeine,  heroine,  as  well 
as  belladonna  with  its  alkaloid  atropine.  If  we  desire  only  to  check 
frequent  discharges,  there  is  no  better  remedy  than  tincture  of  opium 
or  deodorized  tincture  of  opium  in  10-drop  doses  three  times  per  day. 
One  must  not  employ  opium  at  the  beginning  of  the  diarrhea,  but 
allow  the  noxious  contents  of  the  intestines  to  escape,  or  possibly  aid 
this  act  by  calomel  or  castor  oil.  It  is  sometimes  difficult  to  decide 
just  the  point  where  the  opium  therapy  is  in  order.  Perhaps  the  best 
way  is  to  watch  the  stools;  if  they  are  watery,  possess  no  longer  a 
putrefactive  odor,  and  there  is  much  tenesmus,  then  is  the  time  for 
the  employment  of  our  agent.  In  chronic  and  nervous  diarrhea, 
opium  is  wholly  contraindicated  because  it  does  not  modify  the  con- 
ditions producing  the  diarrhea,  and  continued  use  soon  leads  many 
into  the  habit. 

2.  The  second  group  contains  the  astringents  which  contract  the 
blood  vessels  and  diminish  secretion;  hence  they  are  indicated  where 
the  mucous  membrane  has  undergone  pathologic  changes  and  where 
opium  is  contraindicated.  One  must  not  expect  too  much  of  this  group 
of  remedies,  for  the  amount  given  is  small  and  the  length  of  the  in- 
testinal canal  enormous  in  proportion,  and  the  exaggerated  peristalsis 
does  not  allow  the  medicament  to  remain  long  in  contact  with  the  dis- 
eased wall ;  therefore  the  astringent  must  always  be  reinforced  by 
hygienic  and  dietetic  treatment.  The  most  universal  of  this  group  of 
remedies. is  tannin,  and  practically  all  of  the  former  remedies  in  re- 
pute— oak  bark,  choke  cherries,  huckleberries,  etc. — contained  it.  Be- 
cause tannin  soon  acts  unfavorably  on  the  stomach,  several  prepara- 
tions have  been  devised  combining  tannin  with  some  inert  material, 
like  albumen,  gelatine,  etc.,  which  will  aid  its  passage  through  the 
stomach  without  decomposition,  so  that  solution  can  take  place  only 
in  the  duodenum.  Our  own  experience  has  been  confined  to  tannalbin, 
which,  in  doses  of  0.5  gram  (7%  grains)  in  capsules,  taken  four  times 
daily,  proves  very  efficacious.  The  various  others — tannigen,  tan- 
nocoll,  and  tannoform — ^we  have  no  doubt  are  equally  efficient. 

3.  The  third  group,  containing  the  antiseptics,  is  so  numerous  that 
only  a  few  representatives  can  be  mentioned.  These  remedies  check 
diarrhea  by  inhibiting  the  formation  of  putrefactive  products  which 
irritate  the  intestinal  mucous  membrane.  According  to  E.  Schuetz, 
all  efforts  to  render  the  intestine  fully  aseptic  are  in  vain,  and  we  can 


274  DISEASES   OF   THE   DIGESTIVE   TRACT 

only  hope  to  produce  a  modified  form  of  freedom  from  the  bacteria  iu 
its  lumen.  First  we  should  consider  bismuth  preparation,  the  sub- 
carbonate,  the  naphtholate,  the  salicylate,  the  tannate,  and  bismuthose, 
all  of  which  are  best  taken  in  capsules  in  doses  of  0.3  gram  (5  grains) 
four  times  daily.  Unfortunately,  however,  bismuth  acts  on  the 
stomach  by  restricting  its  secretion,  so  that  where  there  is  hypochlor- 
hydria,  as  is  true  in  most  so-called  gastrogenous  diarrheas,  bismuth  is 
contraindicated.  Bismuth  subgallate  (dermatol)  has,  in  addition  to 
its  astringent  action,  a  marked  antiseptic  influence.  It  is  often  well 
to  unite  the  lime  and  bismuth  preparations  with  a  sedative,  as  in  the 
folfowing : 

I^     Codeinae   sulphatis    0.6  grams  or  10  grains 

Mentholis 2.0  grams  or  %  dram 

Bismuthi  subsalicylatis 5.0  grams  or  I14  drams 

Calcii   carbonatis    20.0  grams  or  %  ounce 

M.  Fac.  in  chartulas  aut  capsulas  XX. 

Sig. :      One   every   four   hours. 

We  may  also  include  the  use  of  dilute  hydrochloric  acid  as  a  remedy 
against  diarrhea  when  of  the  gastrogenous  variety,  because,  as  A. 
Schmidt  has  shown,  this  is  often  due  to  hypochlorhydria  or  even 
achylia,  and  the  undigested  connective  tissue  which  passes  into  the 
intestine  forms  an  excellent  culture  medium  for  subsequent  putre- 
factive bacteria,  whose  products  are  an  irritant  to  the  mucous  mem- 
brane. The  use  of  antiseptic  material  against  fermentation  or  putre- 
faction in  the  stomach  is  a  matter  of  dispute.  Probably  the  best  way 
to  check  such  processes  is  by  improving  the  motility  of  the  stomach, 
which  is  much  more  easily  said  than  accomplished,  for  in  this  effort 
particularly  our  success  is  not  of  the  best.  Stiller 's  resorcinol  has 
proved  in  my  hands  as  good  a  means  for  this  purpose  as  any,  while 
next  to  it  comes  saccharin,  given  in  doses  of  0.06-0.3  gram  (1-5  grains) , 
dissolved  in  hot  water.  Ichthyol,  too,  in  capsules  containing  0.2  gram 
(3  grains),  taken  directly  after  meals,  has  served  me  well  in  many 
cases,  but  unpleasant  eructations  usually  follow  its  use,  and,  on  account 
of  this,  ichthalbin,  a  combination  with  albumen,  can  be  used,  but  in 
decidedly  larger  dose  of  0.6-2  grams. 

SURGICAL   TREATMENT   OF    THE   GASTROINTESTINAL 

CANAL. 

Every  internist  must  eventually  reach  conditions  in  the  treatment 
of  the  gastrointestinal  tract  which  cannot  be  managed  with  the  ordi- 


TREATMENT   OP   DIGESTIVE   DISORDERS  275 

nary  means  of  medical  treatment,  such  as  massage,  baths,  medicines, 
etc.  These  are  comprised  in  such  pathologic  states  as  adhesions, 
chronic  ulcers,  stenosis,  hernia,  and  mechanical  difficulties  of  a  similar 
nature.  Hence  he  must  proceed  to  seek  the  aid  of  a  surgeon,  and  pre- 
scribe an  operation  in  exactly  the  same  manner  as  he  would  prescribe 
medicine  or  massage.  After,  however,  the  operation  has  been  per- 
formed he  must  never  consider  that  his  duties  end,  as  this  procedure  is 
often  only  a  preliminary  undertaking  to  some  successful  and  effective 
treatment  by  the  means  which  have  already  been  mentioned.  A  great 
mistake  is  made  by  the  physician  in  giving  up  the  patient  to  a  sur- 
geon and  then  regarding  his  own  liabilities  as  having  ceased.  Many 
a  case  of  gastroenterostomy  has  failed  ultimately  to  grant  the  desired 
relief  to  the  patient  simply  because  diet  was  neglected  after  the  con- 
valescence. 

While  at  present,  and  wisely  so,  medicine  and  surgery  are  distinctly 
divided,  yet  it  behooves  the  physician  to  have  a  clear  idea  of  what 
surgical  means  will  aid  his  patient.  To  accomplish  this,  his  knowl- 
edge should  not  be  limited  to  an  acquaintance  with  only  the  literature 
of  surgery,  but  he  should,  as  far  as  possible,  attend  every  operation 
on  his  patients  and  advise,  if  necessary,  in  any  case  after  the  abdomen 
has  been  opened  on  account  of  the  fact  that  his  diagnosis  can  never  be 
absolute,  as  well  as  a  means  of  increasing  his  knowledge  of  pathologic 
conditions  by  personal  observation — autopsy  in  vivo,  as  it  is  sometimes 
called. 

This  presentation  of  the  surgical  treatment  can  be  systemized  in 
considering,  first,  the  indications  for  operation;  second,  the  appro- 
priate surgical  procedure ;  and  third,  the  results. 

Esophagus. — Under  this  division  of  the  alimentary  tract  we  will  first 
consider  cardiospasm,  which  not  infrequently  causes  the  physician 
a  great  deal  of  difficulty,  though  not  ordinarily  a  dangerous  com- 
plaint. 

For  strictures  resulting  from  cardiospasm,  excellent  results  have 
been  obtained  by  the  use  of  rubber  bulbs,  which,  collapsed  and  passed 
through  the  stricture  into  the  stomach,  are  then  moderately  dis- 
tended with  air  and  drawn  back  through  the  stricture.  These 
manipulations  often,  after  eight  days,  produce  a  perfect  and  per- 
sistent cure.  Very  often  simple  passage  of  a  large,  hard  esophageal 
bougie  may  prove  effective,  provided  that  no  pocket  exists  which  de- 
flects the  instrument  from  its  way  through  the  esophagus  to  the 
stomach.  Furthermore,  the  method  introduced  by  Mixter  of  tying 
a  piece  of  thread  to  a  fragment  of  bread  and  allowing  the  patient  to 


276  DISEASES   OF   THE   DIGESTIVE   TRACT 

swallow  it,  over  which  a  sound  may  be  threaded,  will  accomplish  the 
purpose  when  bougies  fail  to  enter  the  narrowed  passage. 

Myer,  too,  reports  eleven  eases  of  cardiospasm  with  obstruction  of 
the  esophagus,  of  which  seven  were  treated  by  stretching  the  cardia. 
Of  these,  five  resulted  in  a  complete  cure. 

Foreign  bodies  in  the  esophagus  frequently  require  the  aid  of  sur- 
gery. The  most  common  of  these  is  probably  false  teeth  which  have 
been  swallowed  in  sleep  or  during  an  attack  of  coughing,  and  whose 
presence  produces  very  unfavorable  symptoms.  If  the  obstacle  is  too 
low  to  be  readily  grasped  with  forceps,  Franke  recommends  that  an  in- 
cision should  be  made  in  the  side  of  the  neck,  which  will  extend  to  the 
esophagus,  but  not  into  it.  In  this  way,  by  manual  manipulations, 
such  foreign  bodies  can  often  be  moved  toward  the  mouth  so  that  they 
can  be  seized  with  forceps.  The  advantage  of  this  method  of  treat- 
ment is  the  avoidance  of  cellulitis,  so  frequently  set  up  by  the  dis- 
charge of  bacteria  containing  secretions  from  the  esophagus,  and  the 
shortening  of  convalescence. 

Benign  strictures  often  arise  from  syphilis  or  mechanical  injuries  to 
the  esophagus.  When  they  exist,  either  with  or  without  a  divertic- 
ulum, they  are  to  be  treated,  according  to  Sencert,  in  the  following 
manner:  When  the  simplest  sound  can  be  passed,  progressive  dilata- 
tion is  to  be  pursued ;  if  not,  then  esophagostomy,  under  the  direction 
of  the  esophagoscope.  If  the  stricture  cannot  be  distended,  or  if,  from 
efforts  toward  this  object,  inflammation  occurs,  gastrostomy  is  recom- 
mended. If  the  stricture  cannot  be  passed,  then  gastrostomy  is  de- 
manded, with  efforts  at  dilatation  from  below.  If  this  is  not  success- 
ful and  if  emaciation  still  persists,  an  esophago-jejuno-gastrostomy 
must  be  performed. 

The  artificial  formation  of  an  esophagus  is  especially  difficult  on  ac- 
count of  the  frequent  possibility  that  the  separated  intestinal  part 
which  is  carried  through  the  artificial  canal  toward  the  neck  may  un- 
dergo necrosis.  Under  these  conditions,  Krogius  urges  a  radical  opera- 
tion— that  is,  resection  in  all  cases  of  benign  esophageal  stenosis.  Only 
nine  such  operations  have  been  reported,  while  he  reports  two  more,  in 
all  of  which,  with  one  exception,  the  results  have  been  satisfactory, 
both  as  to  life  and  the  removal  of  the  obstruction.  He  recommends, 
at  first,  efforts  to  overcome  the  narrowing  by  means  of  sounds,  and 
urges  the  passage  of  sounds  through  a  gastrostomy  wound  if  the 
former  efforts  are  unsuccessful.  If  this  fails,  however,  he  recom- 
mends strongly  the  radical  operation  after  the  installation  of  a  gastric 
fistula,  through  which  the  patient  may  be  fed  for  sometime  after  the 


TREATMENT   OF   DIGESTIVE  DISORDEUS  277 

operation.  He  concedes  that,  while  this  is  successful  in  benign  stric- 
tures, such  operations  for  cancer  of  the  esophagus  rarely  terminate 
favorably. 

With  malignant  growth  of  the  esophagus  we  have  an  entirely  dif- 
ferent proposition,  and  one  which  resists  the  utmost  efforts  of  the 
surgeon.  Myer  recommends  that  in  operable  cancer  of  the  esophagus 
the  latter  should  be  separated  above  the  growth,  should  be  anchored 
outside  the  thorax,  and  then  a  new  esophagus  formed  under  the  skin 
and  united  with  the  upper  fragment  of  the  old  one.  This,  according 
to  him,  is  much  more  satisfactory  than  to  simply  establish  a  gastric 
fistula. 

As  can  be  readily  seen,  these  operations,  of  the  greatest  severity  in 
character,  are  only  palliative,  and  the  custom  has  grown  of  establish- 
ing, instead  of  the  gastric  fistula,  a  jejunal  fistula,  through  which  the 
patient  may  be  fed  by  a  permanently  introduced  rubber  tube.  My  ex- 
perience, however,  has  been  that  patients  have  emaciated  rapidly,  and 
death  has  usually  been  a  matter  of  a  few  days  or  weeks. 

Stomach  and  Duodenum. — The  simple  gastric  and  duodenal  ulcer, 
as  well  as  the  callous  gastric  ulcer,  often  demand  operation  for  their 
relief.  These  cases  are  often  of  long  duration,  with  repeated  attacks 
and  long  periods  of  freedom  from  attack,  but  can  rarely,  if  ever,  be 
pronounced  cured,  if  chronic,  by  medicinal  treatment. 

The  operations  for  their  relief  consist  chiefly  in  posterior  gastro- 
jejunostomy, with  or  without  resection.  The  simple  ulcer,  if  situated 
at  or  near  the  pylorus,  is  usually  relieved  by  the  single  operation. 
When,  however,  situated  at  the  lesser  curvature,  or  when  the  so-called 
callous  ulcer  exists,  resection,  if  the  patient's  condition  allows,  is  abso- 
lutely necessary  for  permanent  relief.  The  reasons  for  this  are  largely 
that  gastroenterostomy  does  not  relieve  the  so-called  saddle  ulcer  of  the 
lesser  curvature,  and,  if  the  patient  is  near  the  age  of  50,  there  is,  as 
is  well  recognized,  a  constant  danger  of  cancerous  degeneration. 

Kuettner  argues  in  favor  of  the  resection  of  all  callous  ulcers,  first, 
because  it  is  not  possible  to  distinguish  grossly  such  ulcers  from  cancer, 
and,  second,  because  the  mortality  of  resection  is  not  much  greater 
than  that  of  gastroenterostomy,  while  the  results  of  resection  are 
much  better.  In  substantiation  of  these  points  he  reports  that  of 
twelve  patients  in  whom  gastroenterostomy  was  done  only  for  callous 
ulcer,  five  later  developed  cancer,  and  of  nineteen  who  were  resected, 
seven  showed  cancerous  degeneration  by  microscopic  examination. 

Ray  declares  that,  when  ulcers  are  situated  at  or  near  the  pylorus, 
only  a  gastroenterostomy  is  indicated,  while  in  those  situated  in  the 


278  DISEASES   OP   THE   DIGESTIVE   TRACT 

lesser  curvature  and  in  the  posterior  wall  of  the  stomach  a  resection 
of  that  portion  of  the  stomach  containing  the  ulcer  is  to  be  recom- 
mended. In  general,  resection  is  to  be  preferred  to  excision,  since  by 
the  former  all  the  adjacent  pathologic  portions  of  the  stomach  wall  are 
removed,  thus  avoiding  the  danger  of  subsequent  cancerous  degenera- 
tion. 

Zweig  reports  that,  in  twelve  cases  of  gastroenterostomy  for  gastric 
ulcer  not  situated  at  the  pylorus,  in  seven  instances  results  were  un- 
favorable (four  cases  of  death  and  three  severe  recurrences),  and  in 
only  five  was  there  a  permanent  recovery. 

Riedel  reports  that,  in  eighteen  cases  of  gastric  ulcer  in  which  he 
resected  the  middle  portion  of  the  stomach,  fourteen  reported  them- 
selves completely  restored  to  health  and  able  to  follow  their  usual  pur- 
suits in  life,  and  four  were  personally  seen  by  him  and  found  to  be 
free  from  their  former  symptoms. 

Rubritius  reports  that,  of  one  hundred  and  twelve  cases  in  whom 
gastroenterostomy  was  done  for  ulcer  situated  at  the  pylorus  and  also 
in  the  duodenum,  all  were  restored  to  health ;  also,  in  addition,  bleed- 
ing ulcers  and  perigastritis  were  favorably  influenced. 

Only  such  ulcers  as  are  not  accompanied  by  adhesions  of  the  sur- 
rounding organs  and  tissues  can  be  relieved  by  gastroenterostomy, 
while  large  adherent,  callous  ulcers  must  always  be  resected. 

Claremont,  basing  his  conclusions  on  two  hundred  and  fifty  cases  of 
operated  gastric  ulcer,  declares  that  when  the  posterior  gastroenteros- 
tomy alone  is  employed,  the  mortality  need  not  be  more  than  3.5  per 
cent.  The  subsequent  recovery  from  the  gastric  ulcer  by  means  of 
this  operation  alone  depends  largely  on  its  position.  The  prognosis  is 
just  so  much  more  favorable  the  nearer  the  ulcer  is  to  the  duodenum. 
In  pyloric  ulcers,  62  per  cent  are  relieved  and  in  duodenal  ulcers,  73 
per  cent. 

In  a  resume  of  one  hundred  cases  of  ulcer,  Spischarny  comes  to  the 
conclusion  that  the  permanent  results  of  simple  gastroenterostomy  and 
the  same  with  resection  are  alike.  Immediately  after  the  operation, 
however,  the  mortality  is  much  less  after  gastroenterostomy ;  hence  he 
would  choose  resection  in  only  those  cases  whose  age  and  the  callous 
character  of  the  ulcer  scar  lead  to  the  greater  possibility  of  cancerous 
degeneration. 

Borszeky  reports  concerning  the  treatment  of  gastric  ulcer  by  sur- 
gical procedure  in  the  clinic  at  Budapest,  and  the  results  of  such  opera- 
tions.    A  special  interest  was  aroused  by  the  operative  results  of 


TREATMENT   OP   DIGESTIVE   DISORDERS  279 

callous  ulcer,  which  so  persistently  resists  medicinal  treatment. 
Through  simple  gastroenterostomy  alone  half  of  these  cases  were  cured. 
He  considers  that  the  jejunal  ulcer  after  gastroenterostomy  is  much 
more  common  than  is  supposed,  but  very  often  they  are  not  recognized. 
The  prevention  of  these  postoperative  ulcers  lies  solely  in  the  internal 
treatment  after  the  completed  gastroenterostomy.  This  author  does 
not  recommend  resection  unless  the  nature  of  the  scar  is  in  doubt — • 
that  is,  suspected  of  being  malignant.  Furthermore,  he  considers  that 
gastroenterostomy  has  no  influence  over  the  gastric  hemorrhage  if  the 
pylorus  is  patent,  and  only  a  limited  influence  if  the  pylorus  is  stenosed. 

A  report  from  the  clinic  at  Copenhagen,  based  on  five  hundred  and 
twenty-two  cases  operated  for  gastric  ulcer,  with  the  usual  associated 
conditions  of  perforation,  hemorrhage,  stenosis,  hourglass  stomach, 
and  perigastritis,  shows  that  71  per  cent  were  cured,  6  per  cent  im- 
proved, and  22  per  cent  met  with  no  relief.  No  statement  is  made  as 
to  how  often  resection  and  excision  were  employed. 

With  gastroenterostomy  from  the  clinic  at  Vienna  the  statistics  of 
one  hundred  and  sixty-seven  cases  operated  for  gastric  ulcer  showed 
that  the  mortality  of  the  operative  procedure  has  been  reduced  to  6.6 
per  cent  and  of  simple  gastroenterostomy  to  3.5  per  cent ;  52  per  cent 
were  cured,  15  per  cent  improved,  and  the  remainder  met  with  no  re- 
lief. The  prognosis  improves  with  the  nearness  of  the  ulcer  to  the 
duodenum.  Sixty-two  per  cent  were  improved  with  ulcer  at  the  py- 
lorus, 44  per  cent  when  situated  some  distance  from  it,  and  73  per 
cent  when  in  the  duodenum  itself. 

Perforating  ulcer  of  the  stomach  or  duodenum  also  demands  imme- 
diate surgical  relief.  The  results  of  this  operation  are  often  poor  on 
account  of  the  shock  and  the  loss  of  blood,  yet  it  seems  that  the  follow- 
ing principles  may  be  established.  Operation  is  to  be  recommended 
as  soon  as  a  reasonable  diagnosis  is  established,  but  never,  of  course, 
when  the  patient  is  in  collapse.  Resection  should  never  be  attempted 
at  this  time.  When  the  strength  of  the  patient  will  allow,  a  gastro- 
enterostomy must  be  performed.  It  is  rarely  necessary  to  irrigate  the 
abdominal  cavity,  but  it  should  be  thoroughly  drained. 

Dege,  basing  his  conclusions  on  three  hundred  and  fifty-five  cases  of 
operation  for  perforated  gastric  and  duodenal  ulcers,  finds  a  mortality 
of  48  per  cent  and  recoveries  of  52  per  cent.  As  to  the  character  of 
the  operative  procedure,  no  unanimity  exists.  The  minority  of  sur- 
geons believe  in  resection  of  the  pathologic  portions  of  the  stomach, 
while  some  simply  excise  the  ulcer  site,  and  others  declare  for  the 


280  DISEASES   OF   THE   DIGESTIVE   TRACT 

simple  suture  of  the  ulcer.  If  a  subphrenic  abscess  results,  recovery 
often  follows  from  simple  incision  and  drainage.  The  condition  of  the 
patient  also  counts  in  the  decision. 

Steinthal  reports  twelve  cases  of  gastric  and  duodenal  ulcer  per- 
forating into  the  peritoneal  cavity.  Of  these,  seven  were  rescued  by 
immediate  operation,  and  five  died  twelve  hours  after  the  perforation. 
This  emphasizes  distinctly  the  necessity  of  early  operation. 

The  hourglass  stomach,  resulting  from  scar  tissue  of  an  ulcer,  is 
usually  amenable  to  relief  by  surgical  intervention.  When,  however, 
due  to  cancer,  the  case  is  usually  hopeless,  except  possibly  for  a  palli- 
ative operation.  Two  or  three  operations  have  been  suggested  for 
the  hourglass  stomach,  of  which  the  following  views  have  been  ex- 
pressed by  various  well-known  and  competent  authorities. 

Druard  declares  that  the  hourglass  stomach  must  be  subjected  to 
different  surgical  procedure,  according  to  its  nature  and  origin. 
"When  callous  ulcer  is  present,  it  demands  resection  of  the  stomach 
and  union  of  the  separated  portions.  A  simple  gastroenterostomy  in 
such  conditions  does  not  restore  the  stomach  to  its  normal  condition 
without  a  primary  resection;  furthermore,  the  possibility  of  a  change 
of  a  callous  ulcer  to  a  cancer  must  always  be  borne  in  mind. 

Gastro  crises,  dependent  on  interstitial  changes  of  the  spinal  cord, 
have  always  proven  so  obstinate  to  medical  treatment,  and 
are  accompanied  by  such  prostration  from  pain  and  vomiting,  that 
operative  efforts  are  now  made  for  their  relief.  This  operation  con- 
sists of  a  resection  of  certain  nerve  roots  of  the  intercostals.  Sleuke 
has  performed  this  operation  five  times  for  gastric  crises.  He  bases  no 
great  hope  of  cure  on  the  operation,  partially  on  account  of  the  char- 
acter of  the  illness  and  partially  on  account  of  the  chronic  morphine 
habit  which  all  his  patients  had  acquired.  His  advice  is  that  opera- 
tion should  be  performed  as  early  as  diagnosis  is  established  in  order 
that  the  possibility  of  the  acquisition  of  this  unfortunate  habit  may  be 
avoided. 

Goetz  reports  a  case  of  tabes  with  gastric  crises  in  which  the  Foerster 
operation  was  performed.  Resection  of  the  seventh  and  ninth  inter- 
costal nerves  caused  prompt  relief.  There  is  still  some  doubt  as  to 
which  cases  should  be  operated  in  this  way  and  also  which  nerves  should 
be  severed. 

Gastroptosis  is  another  condition  which  is  favorably  influenced  by 
operative  intervention,  particularly  when  it  occurs  congenitally  in  the 
young, 

"Weiss  reports  a  case  which  was  cured  through  gastropexy.     This 


TREATMENT   OF   DIGESTIVE   DISORDERS  281 

was  accomplished  by  the  fastening  of  the  stomach  to  the  anterior  ab- 
dominal wall. 

Beyer  reports  many  cases  of  the  same  pathologic  condition  relieved 
by  sewing  the  gastric  omentum  to  the  lesser  curvature  of  the  stomach. 
In  this  way  the  stomach  is  raised,  and  in  the  young  remains  perma- 
nently in  this  position. 

Coffey  also  reports  many  instances  of  operation  of  the  ptosed  stomach 
by  means  of  his  so-called  "hammock  suspension,"  and  has  obtained 
some  very  admirable  results. 

Gastric  cancer  can  be  operated  on  with  success,  provided  that  the 
diagnosis  is  made  early,  which  avoids  the  possibility  of  coincident 
metastases. 

Mayo  Brothers  recommend  in  all  cases  of  gastric  cancer  that  one 
operate  as  early  as  possible.  Even  the  presence  of  a  palpable  tumor 
is  no  indication  against  a  radical  operation.  They  believe  that  the  're- 
sults of  operation  in  such  cancers  are  just  as  favorable  as  those  of 
cancer  of  other  organs. 

Bran  established  the  following  principles  for  the  determination  of 
whether  a  cancer  of  the  stomach  is  operable.  To  the  operable  variety 
belong  those  cancers  which  are  palpable,  while  those  which  are  not 
palpable  are  probably  of  the  medullary  character,  and  can  almost  never 
be  removed  by  surgical  procedure.  If  pyloric  stenosis  exists,  an  early 
symptom  of  such  a  growth,  especially  if  it  is  rapid,  although  no 
palpable  mass  can  be  discovered,  there  should  be  an  immediate  pro- 
cedure to  exploratory  laparotomy.  Rapid  emaciation  and  cachexia 
often  accompany  a  pyloric  malignant  growth,  and  indicate  an  early 
operation.  The  absence  of  hydrochloric  acid  and  the  presence  of  lactic 
are  of  absolutely  no  value  in  determining  the  advisability  of  operation. 

Pers  found  that,  of  thirteen  patients  with  carcinoma  of  the  stomach 
in  whom  resection  was  done,  two  were  still  living  respectively  five  and 
eight  years  after  operation,  two  were  living  two  and  one-half  years, 
two  were  living  one  and  one-half  years,  and  the  remainder  died  during 
the  first  year. 

Weil  reports  the  results  of  one  hundred  and  fifty-seven  resections 
of  the  stomach,  of  which  thirty-five  were  done  for  gastric  cancer.  Of 
one  hundred  and  thirty-five  of  these,  only  thirty-one,  or  22%q  per 
cent,  survived  the  operation.  Of  the  thirty-one  who  survived 
the  operation,  four  lived  more  than  five  years,  five  more  than 
four  years,  five  more  than  three  years,  and  the  remainder  from 
one  to  two  years  after  the  operation.  Of  all  this  vast  number  who 
were  operated  for  cancer,  l%o  P^r  cent  were  permanent  cures.    These 


282  DISEASES   OP   THE   DIGESTIVE   TRACT 

unfavorable  results  are  unquestionably  due  to  the  advanced  stage  of 
the  disease  when  the  operation  was  performed! 

Pans  has  collected  statistics  in  one  hundred  cases  of  operation  for 
gastric  cancer.  Of  these,  with  simple  exploratory  laparotomy,  there 
was  13%^  per  cent  mortality;  with  gastroenterostomy,  16  per  cent 
mortality;  and  with  resection,  26^0  P^r  cent,  of  which  last  31^io  P^r 
cent  remained  free  from  recurrence  more  than  three  years  after  opera- 
tion. 

Kocher  reports  one  hundred  and  forty  resections  of  the  stomach  for 
cancer.  In  the  first  fifty-two  the  mortality  was  S-i%Q  per  cent;  in 
the  second  series  of  forty-seven  cases,  17  per  cent ;  and  in  the  last  forty 
cases,  only  9  per  cent.  Of  forty  who  survived  the  operation,  two  died 
from  subsequent  complications,  and  twenty-two  from  recurrence  at 
longer  or  shorter  periods  after  discharge  from  the  hospital.  Thirteen 
are  still  living  of  tliose  operated  during  the  last  six  years.  The  num- 
ber of  permanent  recoveries  is  limited  to  thirty  cases.  The  site  of  these 
gastric  cancers,  most  common,  was  the  pylorus. 

Daneel,  reporting  from  the  clinic  at  Heidelberg,  states  that  in 
seventy-five  cases  operated  for  gastric  cancer  the  mortality  was  28 
per  cent.  The  chief  causes  of  death  after  operation,  are  peritonitis, 
collapse,  and  pneumonia.  The  number  of  deaths  occurring  after  con- 
valescence amounts  to  thirty-nine,  of  which  thirty-six  died  from  recur- 
rence. 

Intestines. — Duodenal  and  jejunal  ulcers  frequently  demand  opera- 
tion, both  on  account  of  the  resulting  strictures  as  well  as  the  rarer 
accident  of  perforation.  In  the  former  ease  there  is,  of  course,  no 
urgency;  in  the  latter,  the  more  rapidly  surgical  procedure  is  em- 
ployed the  greater  the  chances  of  the  patient  for  recovery. 

Harris  reports  the  operation  of  six  cases  of  constriction  of  the 
duodenum  by  abnormal  folds  of  hepatocolic  ligament.  The  symptoms 
were  those  of  a  typical  duodenal  ulcer  or  gallstones. 

Jejunal  ulcer  is  often  the  outcome  of  a  previous  gastroenterostomy, 
but  that  result  occurs  much  less  often  since  the  posterior  operation  has 
been  employed.  Whether  jejunal  or  duodenal,  excellent  results  have 
been  secured  by  pursestring  suture  around  the  ulcer  scar.  Excision 
has  never  been  recommended. 

Syphilitic  and  tubercular  strictures  of  the  ileum  often  demand  sur- 
gical treatment.  These  two  are  of  a  chronic  character,  and  abundant 
time  is  given  for  the  establishment  of  a  diagnosis. 

Goto  considers  operation  most  advisable  for  intestinal  syphilitic 
strictures   of   the    ileocecal   region.     One   case   died   after   operation 


TREATMENT   OP   DIGESTIVE   DISORDERS  285 

because  the  resection  could  not  be  successfully  carried  out.  He  re- 
gards the  favorite  site  of  syphilitic  intestinal  strictures,  apart  from 
those  of  the  rectum,  to  be  in  the  upper  middle  portions  of  the  ileum. 

The  same  author  reports  four  cases  of  simple  chronic  inflammatory" 
stricture  of  the  intestine,  of  which  three,  on  account  of  having  been 
taken  for  true  tumors,  were  resected,  and  only  after  the  pathologic 
examination  were  found  to  be  of  a  simple  inflammatory  character. 
He  recommends  medicinal  means  heartily,  but,  if  these  are  ineffectual^ 
a  resection  of  the  diseased  portion — first,  because  the  differential  diag- 
nosis from  true  malignant  growth  is  often  impossible  on  the  operating- 
table,  and,  second,  the  growth  of  a  cancer  at  the  site  of  the  scar  tissue 
is  possible. 

Derk  writes  concerning  the  prognosis  of  extensive  resections  of  the 
small  intestine.  Resections  of  at  least  half  of  the  small  intestines,  300 
em.,  if  the  patient  can  withstand  the  immediate  operation,  is  followed 
by  permanent  favorable  results.  After  a  resection  of  two-thirds  of 
the  entire  length  of  the  small  intestine,  an  unfavorable  outcome 
always  follows ;  sometimes,  however,  only  after  years.  Such  extensive 
resections,  then,  are  never  to  be  undertaken  except  when  life  is  threat- 
ened. 

Our  personal  experience  is  that,  at  least  with  tubercular  stenoses, 
the  operation  is  best  performed  in  two  stages  on  account  of  the  wasted 
condition  of  the  patient ;  in  the  first  of  which  the  strictures  are  short- 
circuited  by  ileoeolostomy,  and  the  diseased  portions  resected  later 
when  the  patient's  strength  has  been  restored.  A  peculiar  feature 
often  present  is  a  persistent  diarrhea,  which  resists  forced  feeding  very 
strongly. 

Incised  wounds  of  the  intestine  usually  require  immediate  surgical 
attention. 

Kahn  declares  that  operation  should  take  place  immediately  when 
any  of  the  following  symptoms  are  present :  collapse  of  varied  degree ; 
excessive  vomiting;  intestinal  obstruction;  frequent  urination:  intense 
pain  in  the  abdomen ;  a  pulse  which  is  at  first  slowed,  but  finally  be- 
comes rapid ;  superficial  and  rapid  respiration  ;  a  slight  rise  of  temper- 
ature and  a  loss  of  liver  dullness,  with  flatness  in  the  lower  abdomen, 
induced  by  blood  or  the  accumulation  of  fluid  and  wdth  rigidity  of  the 
abdominal  muscles. 

]\Iagula  reports  three  hundred  and  one  perforating  wounds  of  the 
abdomen,  injuring  either  the  stomach  or  the  intestines.  In  general, 
such  wounds  heal  kindly  without  complications ;  hence  it  is  advisable, 
after  enlarging  the  wound  and  its  inspection,  to  sew  the  severed  walls 


284  DISEASES   OF   THE   DIGESTIVE   TRACT 

together,  especially  when  not  more  than  twelve  hours  have  passed 
since  the  injury  was  received. 

Ileus  or  obstruction  of  the  intestine  at  any  point  demands,  of  course, 
immediate  surgical  relief  after  the  ordinary  medical  treatment  has 
proven  ineffectual. 

Lerke  reports  five  cases  of  gallstone  obstruction  of  the  ileum 
which  were  later  characterized  by  the  relatively  benign  character  of 
the  intestinal  obstruction  and  the  mild  character  of  the  initial  symp- 
toms. The  patient  should  be  operated  as  soon  as  the  diagnosis  is 
made. 

Krogius  recommends  in  all  cases  of  postoperative  ileus  symptoms, 
when  a  general  operation  is  out  of  the  question,  an  immediate  en- 
terostomy as  soon  as  clysters  are  found  to  be  without  avail  and  the 
symptoms  begin  to  be  dangerous.  When  the  original  operation  is  per- 
formed for  intestinal  obstruction  with  excessive  dilatation  of  the  in- 
testinal coils,  an  enterostomy  is  recommended  immediately  after  the 
primary  operation  as  a  means  of  prophylaxis. 

Appendicitis  in  recent  years  has  demanded  almost  exclusively  the 
attention  of  the  surgeon.  jNlild  cases,  unquestionably,  may  be  treated 
by  medicinal  means,  but  on  account  of  the  vagueness  of  the  attack,  and 
one's  inability  to  determine  when  a  mild  attack  may  become  serious, 
it  is  always  wise  for  the  internist  to  be  in  close  communion  with  a 
surgeon  who  may  be  secured  early  if  necessary.  When  to  operate  in 
appendicitis  has  been  discussed  for  years  wdth  somewhat  varying 
opinions.  An  attempt  will  be  made  here  to  give  the  views  of  some 
of  the  more  prominent  surgeons. 

Based  on  five  hundred  and  sixty  operated  cases,  Hagmaier  comes 
to  the  conclusion  that  many  cases  of  appendicitis  reach  the  surgeon's 
hands  through  the  abuse  of  laxatives,  and  that  every  individual  who 
has  passed  through  one  attack  should  always  remain  in  the  vicinity 
where  competent  surgical  aid  is  at  hand. 

Wanner  regards  appendicitis  during  pregnancy  a  much  more  seri- 
ous illness  than  at  any  other  period,  and  its  prognosis  just  so  much 
more  unfavorable  the  nearer  to  confinement  the  woman  is.  Generally, 
peritonitis  occurs  more  easily  and  there  is  greater  danger  of  general 
sepsis.  This  author  has  operated  five  cases,  and  in  only  one  case  did 
the  mother  fail  to  carry  the  child  to  term.  Early  operation  is  always 
recommended. 

Loewy  insists  that  appendicitis  in  individuals  beyond  51  years  of 
age  is  a  very  rare  occurrence.  It  produces  chiefly  an  abscess  in  the 
iliac  fossa  and  manifests  itself  by  slight  local  symptoms  and  decided 


TREATMENT   OF   DIGESTIVE  DISORDERS  285 

disturbance  of  the  general  condition  of  the  patient;  hence  the  diag- 
nosis is  made  extremely  difficult.  The  operative  results  for  this  rea- 
son are  very  unfavorable  on  account  of  the  frequent  complications. 

Fromme  regards  an  early  operation  as  the  best  treatment  for  ap- 
pendicitis. When  an  abscess  is  present,  it  is  not  wise  to  seek  for  the 
appendix  in  order  to  remove  it.  It  is  usually  sufficient  to  make  a 
slight  incision  for  the  escape  of  the  pus.  After  it  is  discharged  it  is 
not  absolutely  necessary  to  advise  an  interval  operation,  as  only  a 
few  ever  experience  a  recurrence  under  these  conditions.  The  inter- 
nal operation  is  to  be  performed  after  mild  attacks  as  soon  as  no  other 
symptoms  exist.  After  severe  attacks,  one  should  wait  from  four 
to  eight  weeks  before  operation.  The  appendix  is  always  to  be  re- 
moved. 

Kuenunel  urges  early  operation  for  appendicitis.  If  operation  oc- 
curs at  this  period,  the  danger  is  vastly  lessened,  and  the  mortality 
in  his  hands  sank  to  0.6  per  cent,  if  the  operation  occurred  within 
the  first  forty-eight  hours.  The  earlier  the  removal  of  the  appendix 
takes  place  after  appendicitis  is  diagnosed,  the  surer  and  more  harm- 
less does  the  convalescence  follow. 

Zander,  reporting  a  large  number  of  cases  of  appendicitis  from 
the  Halle  clinic,  declares  that  9.7  per  cent  of  all  sufferers  die  from 
their  attack. 

Dolbrucki  reports  three  cases  of  appendicitis,  of  which  two  were 
accompanied  with  hematemesis.  In  one  of  these  cases  a  diagnosis  of 
perforation  and  gastric  ulcer  was  made.  The  operation,  however, 
showed  full  integrity  of  the  stomach.  The  removal  of  the  appendix 
brought  complete  cure.  The  blood  found  in  the  vomitus  was  ab- 
solutely fresh.  The  third  case  distinguished  itself  exclusively  by 
dyspeptic  symptoms  and  the  operation  showed  an  appendix  completely 
filled  with  pus.     Its  removal  was  followed  by  complete  recovery. 

Herman  believes  in  exclusive  operative  treatment  for  appendicitis 
when  the  diagnosis  is  positive.  The  patient  should  be  operated  within 
thirty-six  hours  of  the  beginning  of  the  illness.  Wherever  an  abscess 
already  exists,  the  surgeon  should  attempt  to  remove  the  appendix 
and  not  be  content  with  simply  opening  the  abscess ;  otherwise  a  period 
is  often  reached  in  w^hich  operative  treatment  is  too  late. 

Sehmitler,  basing  his  views  on  two  thousand  operations  for  appen- 
dicitis, declares  that  operation  in  all  severe  cases  must  be  performed 
within  forty  hours  after  the  attack  occurs.  In  other  cases,  one  must 
use  discretion.  The  interval  operation  is  always  to  be  recommended 
whenever  a  previous   attack  can  be  established  and  also  after  the 


"286  DISEASES   OP   THE   DIGESTIVE   TRACT 

severest  attacks,  since  the  appendix  after  such  attacks  is  never  ob- 
literated by  disease. 

Duvergey  advises  secondary  laparotomy  for  cases  of  appendicitis 
in  which,  on  account  of  the  first  delayed  operation,  peritoneal  adhesions 
-and  bands  have  been  formed,  which  produce  extreme  pain  in  the  iliac 
fossa.  These  pains  may  extend  over  the  entire  abdomen,  and  are 
rarely  associated  with  vomiting  and  obstruction. 

Kraft,  basing  his  opinion  on  two  hundred  and  forty-seven  cases  of 
Appendicitis,  with  mortality  of  10  per  cent,  urges  an  early  operation. 
Of  these,  one  hundred  and  thirty-six  were  operated  within  forty-eight 
hours,  with  only  three  deaths,  or  2.2  per  cent.  The  mortality  steadily 
increases  with  each  hour's  delay  after  two  days'  duration  of  the  ill- 
ness. 

Rubesch  discusses  the  operative  treatment  of  tuberculous  ileocecal 
tumors  as  follows:  Immediate  operative  results  for  the  enteroanasto- 
mosis  were  8  per  cent  of  deaths,  while  resection  showed  a  death  rate 
of  10  per  cent.  The  enteroanastomosis  is  only  a  palliative  operation, 
And,  whenever  possible,  resection  is  to  be  carried  out. 

With  immovable  tumors,  anastomosis  is  usually  recommended  when- 
ever the  condition  of  the  patient  permits,  with  closure  of  the  adjacent 
portions  of  the  intestine.  Four  cases  which  were  operated  showed 
multiple  tubercular  strictures  in  the  small  intestine. 

Eschenbach  reports  twenty-four  radical  operations  for  tuberculosis 
of  the  ileocecal  region,  in  which  only  twice  could  a  simple  resection 
of  the  cecum  be  carried  out.  In  all  others  the  entire  ascending 
colon,  and  often  more,  had  to  be  resected.  Seven  died  from  im- 
mediate results  of  the  operation.  In  three  instances,  only  a  palliative 
enteroanastomosis  could  be  carried  out.  Of  those  who  underwent  the 
operation  successfully,  three  died  later  of  pulmonary  tuberculosis. 
The  final  results  of  the  other  cases  were  very  favorable,  which  is  to 
be  considered  particularly  fortunate  on  account  of  the  fact  that  they 
were  all  well  advanced  instances  of  the  disease. 

Thiemann  reports  twenty -six  cases  of  tuberculosis  of  the  mesentery 
glands.  Of  fifteen  of  these,  with  tuberculosis  in  the  ileocecal  region, 
thirteen  were  restored  to  perfect  health  by  means  of  the  operation. 

Cecum  m,ohile  has  of  recent  years  become  a  fair  field  for  the  at- 
tack of  the  surgeons. 

Steinhill  publishes  the  results  of  sixty-one  cases  of  cecum  mobile. 
The  diagnosis  was  based  largely  on  colicky  attacks  in  the  region  of 
the  cecum  and  ascending  colon,  associated  with  persistent  constipa- 
tion, alternating  with  diarrhea  at  the  end  of  the  painful  attacks.     The 


TREATMENT   OF   DIGESTIVE   DISORDERS  287 

permanent  results  of  the  operation  were  75  per  cent  recoveries,  16 
per  cent  improved,  and  4  per  cent  unaffected. 

Sailer  describes  five  cases  of  cecum  mobile  in  which  the  appendix 
w'as  removed  without  result.  The  symptoms  are  ascribed  by  him  more 
to  an  atony  of  the  colon  and  the  accompanying  colitis  than  the  cecum. 
He  is  not  very  heartily  in  favor  of  an  early  operation,  putting  more 
■dependence  on  a  regulation  of  the  stools  and  an  appropriate  diet. 

Finklestein  declares  that  the  most  of  malignant  growths  of  the  large 
intestine,  with  the  exception  of  the  rectum,  are  found  at  the  sigmoid, 
(44  per  cent  of  all  cases)  ;  then  follows  the  cecum,  with  20  per  cent; 
40  per  cent  of  all  such  cases  proved  themselves  nonamenable  to  the 
radical  operation.  In  more  than  35  per  cent  there  was  evidence  of 
stenosis  M^hen  first  seen.  Excision  of  the  growth  of  the  large  intestine 
proved  two  to  three  times  as  successful  with  reference  to  ultimate 
results  as  the  removal  of  the  growths  of  the  remaining  intestinal 
<5anal. 

According  to  Korte  the  special  dangers  associated  with  resection  of 
the  colon  for  malignant  growth  are  collapse  and  peritonitis.  Where 
intestinal  obstruction  is  acute,  all  that  one  can  do  is  to  relieve  the 
obstruction  by  colostomy  and  defer  the  removal  to  a  secondary  opera- 
tion. The  prospects  of  a  permanent  cure  after  removal  of  the  growth 
in  the  large  intestine  are  relatively  favorable. 

Denk  recommends  radical  operation  for  the  extirpation  of  colon 
•cancer.  He  has  already  done  thirty-nine  such  operations,  of  which 
tw^enty  survive.  Of  these,  three  years  after  the  operation,  seven  are 
apparently  absolutely  cured  and  have  never  had  any  recurrence. 

Haberer  reports  the  operation  of  nineteen  cases  of  colon  cancer,  of 
whom  three  died  at  the  close  of  the  operation.  Of  the  remainder, 
all  w^ere  restored  to  health. 

Schmidt,  basing  his  opinion  on  sixty-three  operations  for  tumor  of 
the  large  intestine,  considers  resection  as  the  most  commendatory 
procedure.  Only  when  technical  difficulties  are  present,  or  when  the 
condition  of  the  patient  is  poor,  should  the  operation  ever  be  per- 
formed in  two  stages. 

Cancer  of  the  rectum  has  been  attacked  by  the  surgeon  from  dif- 
ferent routes.  If  low  down,  it  can  be  removed  through  the  anus;  if 
liigher  up,  the  Kraske  operation  is  to  be  preferred.  Often,  however, 
the  combined  operation  is  necessary  to  remove  all  the  growth. 

Reiss  recommends  the  combined  operation  for  cancer  of  the  rectum 
Tinder  the  following  conditions:  first,  when  one  cannot  reach  the 
^o\^i:h  from  below;  second,  when  palpable  glands  can  be  found  high 


288  DISEASES   OF   THE   DIGESTIVE   TRACT 

up;  third,  in  cancers  of  the  true  pelvic  colon,  where  this  method  is 
superior  to  the  single  method.  Danger  of  gangrene  cannot,  however, 
be  absolutely  excluded. 

Ritter  reports  a  restoration  of  continence  after  excision  of  the  rec- 
tum for  carcinoma. 

Torikata  reports  eight  operated  cases  of  rectal  cancer  in  men,  by 
means  of  the  combined  operation,  of  whom  three  died.  The  results 
are  not  inferior  to  those  of  the  dorsal. 

Zinner  insists  that  in  the  operation  for  cancer  of  the  rectum,  even 
when  situated  high  up,  by  means  of  the  sacral  route,  the  opening  of 
the  abdomen  should  be  employed  only  in  the  most  extreme  cages.  Of 
three  hundred  and  twenty  operated  cases,  forty-four,  or  13.75  per 
cent,  died  from  the  immediate  effects  of  the  operation. 

Two  hundred  and  fifty-six  cases  have  been  heard  from  at  a  period 
of  three  years  after  the  operation.  Of  these,  thirty-five  died  from 
intercurrent  diseases  and  one  hundred  and  twenty-seven  from  recur- 
rence of  the  cancer.  Fifty-two  are  still  living,  without  any  evidence 
of  the  disease. 

A  few  surgical  procedures  remain,  which  can  be  discussed  briefly, 
and  whose  employment  is  not  nearly  as  universal  as  those  which  have 
already  been  mentioned. 

Colitis  ulcersoa,  according  to  Schmidt,  must  be  treated  by  surgical 
procedure  when  internal  treatment  has  proven  useless.  This  opera- 
tion consists  of  appendicostomy,  stitching  the  stump  of  the  appendix 
to  the  abdominal  wall,  by  which  free  irrigation  can  be  performed 
through  the  entire  colon  to  the  anus. 

Since  the  teachings  of  Lane  have  become  widely  diffused,  intestinal 
stasis  has  taken  on  a  new  significance.  Various  efforts  have  been  made 
to  overcome  this  by  anastomoses  of  the  intestinal  tract. 

Bainbridge  reports  one  hundred  and  six  cases  of  intestinal  stasis 
in  which  the  operation  of  ileosigmoidostomy  or  colostomy  was  per- 
formed. Four  cases  died  from  the  operation,  so  that  the  mortality 
is  not  a  negligible  quantity. 

Strauss  recommends  for  chronic  ulcerous  diseases  of  the  lower  colon 
an  artificial  anus,  either  at  the  cecum  or,  in  case  the  whole  colon  is 
affected,  at  the  lower  end  of  the  ileum.  This  method  is  superior  to 
the  employment  of  irrigation  from  above. 

Goebel  advises,  when  persistent  and  severe  constipation  persists, 
after  the  diagnosis  is  established  by  the  x-ray  of  either  congenitally 
enlarged  sigmoid  or  the  presence  of  a  rectal  valve,  that  one  should 
first  try  hormonal  injections.     If  these  are  insufficient,  an  excision 


TREATMENT   OF   DIGESTIVE  DISORDERS  289 

of  the  valve  should  be  performed,  or,  if  an  enlarged  sigmoid  exists 
without  valve  interference,  resection  should  be  employed.  If,  on  the 
contrary,  with  the  enlarged  sigmoid  a  valve  is  found,  the  valve  should 
first  be  removed.  AVhen  cecum  mobile  is  present,  suspension  should 
be  attempted,  and,  if  this  is  impracticable,  a  portion  of  the  cecum 
should  be  excised. 

Hedlund  reports  four  cases  of  megacolon  which  were  treated  sur- 
gically with  resection  of  the  distended  intestinal  portions  with  or  with- 
out a  preceding  establishment  of  a  preternatural  anus.  He  has  ob- 
served these  cases  both  immediately  after  the  birth  of  the  child  as  well 
as  in  youths  and  not  seldom  in  adults.  The  condition  is  probably 
congenital,  or  brought  on  by  a  twist  of  the  sigmoid  or  of  the  abnormal 
length  of  this  portion  of  the  intestines. 

Cysts  and  diverticula  of  the  colon  are  often  the  object  of  surgical 

intervention,  as  they  obstinately  persist  in  spite  of  medical  treatment. 

Marchetti  reports  a  successful  operation  for  a  cyst  of  the  transverse 

mesocolon.     The  operation  consisted  of  extraction  of  the  cyst,  which 

was  followed  by  perfectly  normal  postoperative  convalescence. 

Brewer  reports  a  case  of  acute  inflammation  of  a  diverticulum  of  the 
sigmoid  flexure.  This  case  had  been  previously  operated  for  the 
same  disease.  In  the  lower  left  abdominal  quadrant  there  was  a 
swelling,  which  was  painful  on  pressure,  and  there  were  also  fever 
and  severe  abdominal  pains.  The  swelling  increased  steadily  in  size 
and  sensitiveness.  Operation  showed  a  diverticulum  that  was  inflamed 
and  contained  pus.     The  patient  eventually  recovered. 

Neupert  reports  two  operated  cases  of  intestinal  diverticulum.  The 
first,  a  diverticulum  of  the  sigmoid  flexure,  had  extended  to  perfora- 
tion and  abscess  formation,  of  which  the  outcome  was  death.  In 
the  second  case  there  was  a  diverticulum  extending  from  the  trans- 
verse colon,  which  was  first  operated  on  for  removal  of  the  distended 
portions,  and,  as  this  was  ineffectual  in  relieving  the  symptoms,  the 
whole  ascending  and  transverse  colon  was  removed  and  the  ileum 
united  with  the  descending  colon.  Convalescence  was  promptly  es- 
tablished, with  the  normal  intestinal  functions. 

Hernia  represents  another  form  of  disease  in  which  we  have  to  seek 
the  assistance  of  the  surgeon.  ]\Iany  cases  progress  comparatively 
well  for  years  with  trusses  and  other  apparatus,  but  we  are  frequently 
called  on  where  strangulation  has  taken  place  and  where  operative 
intervention  must  be  immediate. 

Riedel  declares  that  in  hernia  the  presence  of  intestinal  coils  exists 
much  oftener  than  is  supposed.     The  diagnosis  in  inguinal  and  femoral 


290  DISEASES  OF   THE   DIGESTIVE   TRACT 

hernia  is  difficult  only  when  a  small  portion  of  the  intestine  is  incar- 
cerated and  the  patient  is  indifferent  to  pain.  All  efforts  at  manual 
reposition  are  contraindicated  and  the  rupture  must  be  operated  im- 
mediately. 

Szuraan  has  operated  seventy-eight  inguinal  herni^e  in  sixty-one  chil- 
dren, of  which  two  were  incarcerated.  There  was  no  fatal  termination. 
Recurrences  took  place  in  two  cases.  An  earl}^  operation  is  strongly 
recommended  on  account  of  the  danger  of  a  permanent  hernia.  He 
further  concludes  that  the  wearing  of  a  truss  is  not  always  harmless. 

Van  Assen,  basing  his  experience  on  one  hundred  cases  of  strangu- 
lated hernia,  draws  the  following  conclusions:  Every  strangulated 
hernia  should  be  operated  immediately,  without  any  effort  at  manual 
replacement.  In  the  presence,  however,  of  active  syphilis,  and  an 
infection  of  the  operation  field,  it  is  perhaps  advisable  to  employ 
manipulation,  unless  no  special  contraindication  exists.  With  little 
children,  when  no  general  symptoms  are  present,  it  is  very  often 
possible  by  simply  raising  the  hips  to  cause  the  strangulated  portions 
to  spontaneously  make  their  way  back  into  the  abdominal  cavity.  The 
strangulated  hernia  should,  in  general,  be  operated  by  means  of  local 
anesthesia. 

Eichner  strongly  recommends  operation  for  umbilical  hernia,  which 
should  be  accomplished  in  the  following  stages:  first,  resection  of  the 
sac;  second,  insertion  of  a  pursestring  suture  throughout  all  the  lay- 
ers of  the  tissue  surrounding,  including  the  skin,  outside  the  location 
of  the  wound;  third,  union  of  the  edges  of  the  hernial  opening; 
fourth,  drawing  together  the  pursestring ;  and  fifth,  union  of  the  skin. 

Cepella  calls  attention  to  the  fact  that  whenever  a  hernia  of  the 
linea  alba,  associated  with  gastric  symptoms,  is  simply  closed  by  su- 
ture without  exploratory  laparotomy,  the  results  are  usually  very 
unsatisfactory,  for  under  the  simplest  hernia  severe  gastric  disease 
may  often  lie  concealed.  The  recurrences  of  the  simple  hernia  after 
operation  were  comparatively  large — 12  per  cent. 

While  operations  for  gallbladder  diseases  cannot  strictly  be  regarded 
under  those  of  the  digestive  tract,  still,  gastric  symptoms,  such  as 
eructations,  vomiting,  etc.,  so  frequently  depend  on  the  gallbladder 
affection  that  they  apparently  come  under  this  head. 

Whether  due  to  stones  or  inflammatory  affections  of  the  gallbladder, 
by  which  we  have  produced  a  viscid  bile,  causing  great  discomfort, 
if  not  actual  pain,  after  a  preliminary  course  of  dietetic  and  medicinal 
treatment,  there  is  nothing  left  for  us  but  to  seek  the  aid  of  the  sur- 
geon. 


TREATMENT   OF   DIGESTIVE  DISORDERS  291 

The  surgical  procedure  may  be  either  cholecystostomy  with  drainage, 
or  cholecystectomy,  or  simply  the  removal  of  the  obstructing  stones 
from  the  duct,  yet  it  is  surprising  after  such  operations  how  quickly 
the  former  gastric  symptoms  subside,  often  to  remain  absent  per- 
manently unless  a  reinfection  of  the  gallbladder  occurs. 

Such  operations,  too,  in  our  experience  have  always  proven  very 
harmless,  when  fever  and  jaundice  are  absent,  as  far  as  the  termina- 
tion of  life  is  concerned,  and  there  are  no  other  means  known  to  medi- 
cine, according  to  our  opinion,  by  which  such  results  can  be  pro- 
cured. 

A  similar  condition  is  present,  too,  in  attacks  of  acute  pancreatitis 
or  pancreatic  hemorrhage — the  latter  a  most  fatal  condition,  in  which 
immediate  operation  forms  the  only  means  of  saving  the  patient's 
life. 

Hemorrhoids  and  anal  fistulas,  after  a  moderate  attempt  at  treat- 
ment by  means  of  suppositories  and  rectal  irrigation  has  been  made, 
are  properly  within  the  province  of  the  surgeon,  and  particularly  in 
elderly  people  the  operation  must  not  be  delayed  until  carcinoma  re- 
places the  previous  simple  inflammatory  affection. 


PART  II 
SPECIAL  GASTRIC  DISEASES 


CHAPTER  IX 

ACUTE  AND  CHRONIC  GASTEITIS 

ACUTE  GASTRITIS. 

Causes. — The  causes  of  this  disease  may  be  divided  into  primary 
and  secondary,  of  which  the  former  comprise  the  ingestion  of  spoiled 
or  improperly  prepared  food,  or,  as  has  often  come  under  my  observa- 
tion, instances  where  gross  and  rapid  eating  are  indulged  in  for  a 
certain  period  (weeks  or  months),  when  the  stomach  rebels  and  a 
"bilious"  attack — or,  in  other  words,  an  attack  of  gastritis — occurs. 
Many  of  the  attacks  of  ptomaine  poisoning  occurring  in  summer  are 
only  a  gastritis  brought  on  by  eating  food  which  has  not  been  kept 
fresh  by  ice,  and  sometimes  one  must  acknowledge  that  the  food  is 
probably  unjustly  accused  and  the  indisposition  brought  on  by  the 
incessant  drinking  of  ice  water,  as  these  attacks  are  most  liable  to 
occur  during  the  excessively  hot  weather.  Closely  allied  to  this  form 
of  gastritis  is  that  brought  on  by  continued  use  of  toxic  substances, 
strong  acids,  alkalies,  alcohol,  purgatives,  and  especially  the  mineral 
poisons  used  medicinally,  as  arsenic  (Fowler's  solution)  and  phos- 
phorus. 

Secondary  causes  of  acute  gastritis  are  nephritis  and  gout  (stomach 
gout  of  the  English),  infectious  diseases  (measles,  scarlatina,  erysipe- 
las, and  pneumonia) .  In  this  form,  however,  the  gastric  symptoms  are 
overshadowed  by  the  more  urgent  ones  of  the  disease  itself.  The 
''weak"  stomach,  so-called,  with  its  occasional  attacks  of  indigestion 
when  something  perfectly  edible  "distresses,"  does  not  indicate  that 
its  owner  is  in  any  degree  subject  to  acute  gastritis,  but  is  to  be  classed 
in  the  category  of  nervous  dyspepsia,  for  the  attacks  rarely  last  over 
twenty-four  hours,  and  hence  the  tendency  to  attribute  the  discomfort 
to  the  last  article  eaten. 

Symptoms. — The  symptoms  consist  of  loss  of  appetite — in  fact,  dis- 
gust for  food — nausea,  which  may  increase  until  the  patient  vomits 
several  times,  a  furred  tongue,  and  a  very  offensive  breath.  Increased 
secretion  of  saliva  and  a  feeling  of  pressure  in  the  epigastrium  are 
present,  accompanied  often  by  considerable  tenderness  to  pressure, 

295 


296  DISEASES   OF   THE   DIGESTIVE   TRACT 

but  actual  pain  is  rare.  The  vomitus  is  very  acid  from  fermentation, 
as  the  hydrochloric  acid  is  often  temporarily  suppressed.  The  urine 
is  high  colored,  limited  in  quantity,  usually  contains  urates  as  a  de- 
posit, and  may  contain  a  trace  of  bile,  since  the  duodenum  rarely  es- 
capes involvement  in  the  process.  The  bowels  are  confined,  and  there 
is  usually  no  fever.  Adults  never  have  any  marked  temperature  with 
acute  gastritis,  though  children  may.  When  it  is  necessary  for  the 
author  to  differ  with  colleagues  on  the  diagnosis  of  acute  gastric 
catarrh,  with  the  patient's  temperature  at  104°  and  no  pulmonary 
symptoms,  the  next  day  usually  discloses  a  frank  pneumonia. 

Treatment. — The  treatment  consists  chiefly  in  a  series  of  "do  hots," 
for  every  individual  you  see  with  such  an  attack  has  had  previous 
ones,  and  the  best  cure  is  the  discovery  of  his  particular  indiscretion 
in  diet  and  its  avoidance.     Particularly  in  children  should  one  make 
an  effort,  for  their  "weak"  stomach,  which  the  fond  mother  often 
thinks  is  inherited,  usually  turns  out  to  be  a  much  abused  organ,  and 
the  problem  can  often  be  solved  by  asking  the  parent  to  let  the  child 
eat  in  the  presence  of  the  physician.     The  child  can  often  exceed  the 
"famished  wolf"  in  the  voracity  with  which  it  devours  food.     With 
the  adult  who  steadily  frequents  saloons,  an  acute  gastritis  is  usually 
passed  him  "first  over  the  bars,"  as  a  well-advertised  whisky  has  it; 
not  from  the  inherent  harm  of  a  moderate  amount  of  alcohol,  but  from 
his  repeated  attacks  on  the  bottle,  resulting  from  good-fellowship  and 
treating.     Allusion  has  already  been  made  to  the  fate  of  our  public 
men  who  are  compelled  to  frequently  attend  formal  dinners,  where 
six  to  eight  courses  are  served,  the  "discussion"  of  which  soon  leads 
to  acute  gastritis.     When  we  have  an  infectious  disease  before  us,  we 
must  immediately  place  the  patient  on  the  simplest  diet  in  order  to 
forestall  and  avoid  an  occurrence  of  tTiis  affection,  which  adds  much 
discomfort  and  increased  danger  to  the  original  illness.    The  real  treat- 
ment begins  with  absolute  abstinence  from  food  until  the  nausea  and 
vomiting  cease,  and,  if  the  latter  is  not  effective,  a  gastric  lavage  or 
an  emetic  is  indicated  to  free  the  stomach  from  all  fermenting  rem- 
nants of  food.     The  emetic  had  best  not  be  given  by  the  mouth,  since 
it  aggravates  the  irritation  of  the  stomach,  but  a  hypodermic  should 
be  employed,  consisting  of  apomorphine  hydrochloride,  0.006  gram 
iVio  grain),  which  almost  every  physician  carries  with  him  in  the 
form  of  tablets,  easily  soluble  in  water.     Many  people  are  able  to 
provoke  vomiting  by  thrusting  a  finger  do^Ti  the  throat  or  by  drink- 
ing a  little  mustard  suspended  in  lukewarm  water,  but  these  means 
produce  an  unpleasant  nausea,  which  is  apt  to  continue,  and  do  not 


ACUTE   AND    CHRONIC    GASTRITIS  297 

empty  the  stomach  completely.  It  is  therefore  best,  on  the  whole, 
to  use  the  tube  and  to  wash  out  until  the  wash  water  comes  clear, 
and  it  is  surprising  sometimes  to  note  how  quickly  the  nausea  dis- 
appears after  this  act.  With  small  children  this  is  the  most  effective 
measure  of  all,  for  it  often  prevents  the  subsequent  involvement  of  the 
intestine  so  provocative  of  the  much  dreaded  cholera  infantum.  If 
nausea  continues  after  the  stomach  is  freed  from  debris,  bits  of  ice 
may  be  given  or  cocaine  hydrochloride,  or  it  may  sometimes  be  neces- 
sary to  give  morphine  sulphate,  0.015  gram  (14  grain),  hypodermat- 
ically  to  stay  the  "dry  heaving,"  as  the  clinic  patients  call  it.  Medici- 
nal treatment  for  the  gastritis  itself  is  rarely  required,  but,  if  there  is 
much  acid  eructation  after  the  vomiting  has  ceased,  we  may  employ 
either  of  the  following : 

IJ     Resorcinolis    2.0  or  14  dram 

Magnesii  oxidi     20.0  or  %  ounce 

M.  Fac  in  chartulas  XX. 

Sig. :     One  powder  every  two  hours. 

IJ     Resorcinolis   0..5  or   7^  grains 

Aquae  chloroformi   100.0  or  3  ounces 

M.     Sig.:     Tablespoonful  every  two  hours. 

Diet. — The  diet  for  twentj'-four  to  forty-eight  hours  should  be  con- 
fined to  albumin  water,  or,  unless  the  patient  demands  some  nourish- 
ment, complete  abstinence  for  this  period  is  most  desirable.  This  is 
most  difficult  to  carry  out  in  children,  for  the  mothers  imagine  that 
such  treatment  is  brutal,  and  cannot  understand  that  forty-eight  hours ' 
abstinence  from  food  under  such  conditions  does  not  produce  the 
pangs  of  hunger.  The  child  feels  uncomfortable,  and  often  demands 
food  because  it  imagines  its  discomfort  is  due  to  hunger.  Thirst  may 
be  gratified  by  small  quantities  of  cold  Vichy  water  (a  wineglassful), 
for,  if  larger  quantities  are  taken,  vomiting  is  liable  to  occur.  The 
coated  tongue  may  be  frequently  sponged  with  the  diluted  antiseptic 
solution  of  the  Pharmacopeia,  or  with  lemon  juice,  as  Zweig  recom- 
mends. As  soon  as  the  earlier  symptoms  disappear,  which  rarely  last 
over  forty-eight  hours  if  these  directions  are  followed,  or  as  soon  as 
hunger  reappears,  we  may  give  the  patient  cooked  and  cooled  milk 
(modified  by  tea  or  coffee),  lemonade,  bouillon,  pressed  beef  juice  from 
meat  previously  broiled,  or  gruel  made  from  the  various  grains — 
barley,  wheat,  corn,  or  rice  flour,  strained — or  gelatine.  If  no  un- 
toward symptoms  occur,  we  may  go  on  to  dropped  eggs,  boiled  lean 
white  meat  of  chicken,  raw  oysters,  and  broiled  steak;  the  latter 
chewed  and  the  juice  swallowed,  but  the  fiber  rejected.     These,  with 


298  DISEASES   OF    THE   DIGESTIVE   TRACT 

cream,  will  usually  satisfy  the  patient  for  eight  to  ten  days,  and 
not  until  then  should  he  return  to  his  previous  manner  of  living, 
though  cabbage,  beans,  pease,  and  uncooked  fruit  had  best  be  avoided 
for  some  time  longer.  This  usually  ends  the  attack;  but  sometimes 
the  noxious  material  enters  the  intestine,  and  then  we  have  gas- 
troenteritis, with  colicky  pains  and  several  foul-smelling  stools,  often 
in  a  state  of  active  fermentation.  In  this  case  the  diarrhea  should 
not  be  checked  at  once,  but  encouraged  by  calomel  in  small  doses, 
0,006  gram  (%o  g^^in)?  frequently  repeated,  or  by  castor  oil,  though 
the  latter  is  usually  ejected  by  the  irritated  stomach.  A  teaspoon- 
ful  or  two  of  Carlsbad  salts,  given  in  a  cup  of  very  hot  water  (not 
warm  water),  will  sometimes  be  retained  and  produce  the  desired  re- 
sult. The  rectal  injections  usually  fail  to  correct  the  condition  be- 
cause they  wash  out  only  the  lower  bowel.  If  loss  of  appetite  con- 
tinues, we  may  often  overcome  it  by  10  drops  of  dilute  hydrochloric 
acid,  well  diluted,  taken  after  meals,  because,  if  taken  before,  it  may 
cause  pain  by  acting  on  the  scarcely  restored  mucous  membrane.  Pain 
is  rarely  present,  except  when  the  bowel  is  also  affected,  and,  after 
free  evacuation,  opium  should  be  given  by  suppository  rather  than  by 
mouth  as  extractum  opii  0.03-0.05  gram  (%-%  grain),  to  be  repeated 
only  when  the  pain  is  severe.  The  sense  of  pressure  and  fullness 
over  the  epigastrium  may  be  allayed  by  mustard  leaf  or  cold  com- 
presses. The  restriction  of  the  term  acute  gastritis  to  those  forms 
resulting  from  violent  mineral  poisons  is  ill  advised,  but,  after  the 
antidotes  have  done  their  work,  the  treatment  of  the  resulting  condi- 
tion does  not  differ  from  that  given  above.  The  phlegmonous  gas- 
tritis, on  account  of  its  difficulty  of  detection,  rarely,  if  ever,  pre- 
sents itself  for  treatment,  but,  if  it  does,  surgical  intervention  offers 
the  only  hope. 

CHRONIC  GASTRITIS. 

Causes. — The  causes  which  produce  the  acute  form  may  by  longer 
continuance  cause  the  chronic  variety  after  several  acute  attacks. 

Primarily,  we  have  only  a  repetition  of  the  causes  producing  an 
acute  attack,  but  alcohol  and  purgatives  seem  to  claim  an  equal  num- 
ber of  victims,  but  not  in  the  same  sex.  Furthermore,  the  constant 
use  of  condiments  and  tobacco  may  lead  to  chronic  gastric  catarrh, 
as  it  is  often  called. 

The  secondary  causes  of  this  disease  are  gastric  cancer  and  ulcer, 
dilatations  due  to  pyloric  narrowing,  as  well  as  sometimes  pure  atony 
and  venous  congestion  of  the  gastric  walls  from  old  cardiac  disorders. 


ACUTE   AND    CHRONIC   GASTRITIS  299 

Chronic  gastric  catarrh  often  arises  from  cirrhosis  of  the  liver  and 
emphysema  of  the  lungs  for  the  same  reason — impairment  of  the 
venous  circulation.  Pulmonary  tuberculosis,  too,  is  a  very  common 
cause  of  gastritis,  and  some  enthusiastic  workers  in  the  line  of  gastric 
disorders  make  this  diagnosis,  only  to  have  their  attention  called  to 
concomitant  apex  consolidation,  which  antedates  the  ''dyspepsia,"  as 
the  patient  calls  it.  In  fact,  the  pretubercular  stage  of  phthisis,  as 
it  is  sometimes  termed,  is  ushered  in  by  marked  evidence  of  achylia 
and  gastritis.  Parenchymatous  nephritis  also  goes  hand  in  hand  with 
a  gastric  catarrh,  which  is  also  true  of  diabetes,  whether  from  the 
disease  per  se  or  from  the  enormous  quantities  of  meat  that  is  to  be 
eaten.  There  is  often  an  association  between  pharyngeal  and  nasal 
catarrh  and  gastritis,  but  whether  accidental  is  difficult  to  say.  Many 
claim  that  swallowing  the  mucus  and  pus  of  the  former  brings  on  the 
latter.  In  these  instances  there  is  marked  fetor  ex  ore,  which  does 
not  come  from  the  stomach,  as  the  patient  claims,  and  must  always 
arouse  suspicion  of  antrum  disease.  If  found  and  relieved,  the  gastric 
trouble  usually  subsides.  There  is  also  a  close  association  between 
arteriosclerosis  and  gastritis,  from  which  come  often  the  sharp 
hemorrhages  from  patients  suspected  of  cancer,  but  living  many  years 
after. 

Symptoms. — The  symptoms  divide  the  disease  into  three  stages: 
(1)  gastritis  acida,  resulting  from  a  too  great  use  of  alcohol,  condi- 
ments, and  drastic  laxatives,  where  there  is  always  a  hypersecretion; 
this  passes  gradually  into  (2)  gastritis  anacida,  in  which  the  hydro- 
chloric acid  is  lost,  while  pepsin  and  rennin  are  still  present,  though 
in  diminished  amounts;  after  long  continuance  of  this  condition  the 
disease  reaches  the  last  stage  (3),  complete  achylia  gastrica,  in  which 
both  acid  and  ferments  are  absent  and  the  peptic  glands  are  destroyed 
by  atrophy.  All  of  these  stages  are  associated  with  abundant  mucus, 
so  that  we  may  say,  "No  mucus,  no  gastritis,"  but,  as  described,  the 
mucus  must  be  demonstrated  to  come  from  the  stomach  and  not  by 
any  means  from  the  mouth  (saliva).  The  subjective  symptoms  are 
usually  not  characteristic  of  this  condition;  in  fact,  may  be  latent 
until  an  accidental  examination  of  gastric  contents  shows  irreparable 
mischief  accomplished.  The  appetite  is  erratic,  demanding  foods 
higher  seasoned  and  salads  with  abundance  of  vinegar,  mustard,  and 
pepper.  A  "dark-brown  taste"  on  rising  is  common,  and  patients 
complain  of  "water  brash."  After  food  is  taken,  epigastric  fullness 
and  pressure  are  complained  of,  and,  if  no  gastric  juice  is  secreted,  pa- 
tients complain  of  occasional  lancinating  sharp  pains.     Desquamations 


300  DISEASES   OF   THE   DIGESTIVE   TRACT 

of  the  gastric  mucous  membrane  also  occur,  which  aggravate  the  pain 
and  give  it  the  specific  name  of  exfoliativa  or  erosiva,  which  places  it 
midway  between  a  gastritis  and  an  ulcer.  "Heartburn"  and  acid 
eructations  are  also  present,  but  nausea  and  vomiting  occur  less  often. 
Hard  drinkers  have  the  morning  vomiting,  which  may  be  only  the 
pharyngeal  mucus  which  is  swallowed  during  the  night,  or,  in  our 
opinion,  may  not  come  from  the  stomach  at  all,  but  be  brought  from 
the  nasopharynx  by  a  pseudo  act  of  vomiting,  for  we  have  never  been 
able  to  obtain  any  morning  residue  from  these  patients  with  a  tube. 
Vertigo,  palpitation  of  the  heart,  and  even  a  true  asthma  may  arise. 
The  spirits  of  the  patient  are  low,  and  he  has  many  ungrounded 
fears,  such  as  entering  a  building  where  a  public  gathering  is  as- 
sembled or  the  rear  car  of  a  train ;  these  latter  are  not  peculiar  to  this 
disease,  but  associated.  The  intestinal  functions  are  also  disturbed 
as  a  probable  result  of  catarrh,  for  diarrhea  is  common,  while  constipa- 
tion is  rare.  Objectively,  one  can  usually  find  a  diffused  tenderness 
over  the  epigastrium,  but  no  painful  points;  the  tongue,  on  account 
of  the  existing  pharyngitis,  at  its  posterior  portion  has  a  thick  gray- 
ish-white coating;  the  teeth  are  usually  poor  and  the  molars  may  be 
entirely  wanting,  which  presages  poorly  masticated  food  for  the 
stomach's  manipulations.  The  examination  of  the  gastric  contents, 
however,  gives  us  the  chief  points  for  a  diagnosis.  We  find  abundant 
mucus  in  the  form  of  long  shreds  and  transparent  lumps,  while  with 
the  microscope  these  are  found  loaded  with  leucocytes.  Sometimes  as 
much  as  100  c.c.  of  a  secretion,  largely  mucus,  can  be  obtained  from 
the  fasting  stomach  without  a  trace  of  free  acid,  a  condition  called 
myxorrhea  gastrica  by  Kuttner.  The  behavior  of  hydrochloric  acid 
and  ferments  has  been  mentioned.  The  motility  is  usually  well  main- 
tained ;  in  fact,  the  radiologists  tell  us  that  hypermotility  may  exist, 
but  evidence  derived  from  the  small  portion  obtained  after  a  test 
breakfast  is  not  trustworthy,  and,  as  explained,  usually  rests  on  the 
thickened  consistency  of  the  fluid,  due  to  scanty  secretion  of  gastric 
juice,  which  will  not  allow  the  former  to  flow  through  the  tube.  The 
rapidity  with  which  the  undigested  food  passes  into  the  intestine  has 
been  offered  us  as  an  explanation  of  the  often  concomitant  catarrh 
of  the  small  intestine.  Einhorn  found  often  small  fragments  of 
mucous  membrane  in  the  wash  water  of  these  cases,  accompanied  by 
eructations,  by  diminished  hydrochloric  acid  secretion  and  increased 
mucus  formation,  and  would  make  of  them  a  distinct  disease,  but  this 
is  untenable,  as  they  are  all  manifestations  of  chronic  gastritis.  These 
desquamations,  however,  are  not  spontaneous,  but  are  fragments  torn 


ACUTE   AND    CHRONIC    GASTRITIS  301 

off  by  the  tube,  as  the  interior  of  the  stomach  is  very  vulnerable  in 
this  disease,  and  the  presence  of  these  fragments  forms  an  important 
point  in  differentiating  it  from  a  purely  functional  suppression  of 
gastric  juice  of  nervous  origin. 

Treatment. — The  treatment — like  Dr.  Holmes'  suggestion,  that,  to 
make  a  gentleman  of  a  boy,  you  should  begin  with  his  grandparents — 
should  begin  before  the  disease  appears.  This  suggestion,  however, 
valuable  as  it  is,  is  difficult  to  apply,  for  the  public  man  will  continue 
to  devour  his  two  or  three  formal  dinners  a  week,  followed  usually 
by  an  after-dinner  speech;  the  business  man  will  gorge  himself  on 
Sunday,  his  only  day  at  home;  and  many  a  working  man  is  rarely 
able  to  reach  his  home  without  leaving  a  goodly  portion  of  his  weekly 
earnings  at  the  saloon.  My  lady  will  lead  her  sluggish  life,  driven 
about  in  a  limousine,  striving  to  suppress  the  fact  that  her  indolent 
life  is  adding  steadily  to  her  weight  and  necessarily  to  the  destruc- 
tion of  her  much  prized  form,  and  then  have  recourse  to  someone's 
after-dinner  pills,  until  her  stomach  is,  as  one  such  called  it,  "a  boil- 
ing cauldron. ' '  When  told  what  had  happened  and  why,  almost  every 
patient  remarks,  '*I  thought  that  was  the  cause  of  my  illness,  but  I 
had  not  the  self-restraint  to  resist."  These  primary  " gastritides " 
usually  require  only  a  regulation  of  the  diet,  by  which  laxatives  may 
usually  be  given  up,  though  it  must  be  acknowledged  that  many  cases 
require  the  most  infinite  patience  on  the  part  of  the  physician  to 
finally  eradicate  the  habit  of  their  use. 

The  secondary  type  is,  of  course,  dependent  on  the  primary  dis- 
ease, which  is  often  incurable  (heart  lesions,  cirrhosis  of  the  liver,  and 
pulmonary  emphysema)  and  is  very  resistant  to  treatment.  Rest  in 
bed  and  digitalis  will  usually  relieve  the  first  class,  sodium  phosphate 
and  Carlsbad  salts  the  second,  while  change  of  climate,  if  possible,  and 
iodides  will  relieve  the  third  class  somewhat. 

Diet. — The  diet  must  vary  in  accordance  with  the  character  of  the 
secretion.  If  hydrochloric  acid  is  largely  suppressed,  we  must  rely 
almost  wholly  on  the  carbohydrates,  and  to  a  much  lesser  degree  on 
fats  and  protein.  On  account  of  the  inability  of  the  gastric  juice  to 
digest  the  gluten  inclosing  the  starch,  all  these  grains  and  vegetables 
should  be  thoroughly  crushed  and  well  cooked.  We  have  an  endless 
supply  of  this  group  in  the  innumerable  breakfast  foods — wheatena, 
corn  flakes,  puffed  rice,  etc. — which,  served  with  sugar  and  cream,  or, 
better,  with  salt  and  cream,  form  the  chief  ingredient  in  the  dietary. 
Vegetables,  to  which  butter  is  to  be  added  freely — or,  better,  served 
in  puree  form — chopped  spinach,  mashed  potato,  squash,  and  turnip. 


302  DISEASES  OF   THE   DIGESTIVE   TRACT 

as  well  as  pea  puree,  with  cauliflower  and  asparagus  tips,  are  indi- 
cated. Red  pepper  and  paprika  can  be  used  freely  on  the  principle 
that  the  "hair  of  the  dog  will  cure  the  bite,"  since  overstimulation  of 
the  peptic  glands  by  condiments  has  been  partially  responsible  for  the 
condition.  If  hydrochloric  acid  and  ferments  are  diminished,  meat 
is  not  well  borne,  and  should  be  given  in  the  best  divided  form,  as 
minced  beef,  chicken,  lamb,  fish,  etc.,  all  forms  of  hash  and  the  interior 
of  sausage,  if  not  too  fat,  like  Frankfurters.  Pigs'  feet  and  calves' 
foot  jelly,  eggs  cooked  in  any  form  but  fried,  oysters,  and  the  mild 
cheeses  will  usually  furnish  enough  protein  material  for  the  individual 
in  the  most  assimilable  form.  Somatose  and  laibose,  as  illustrations 
of  the  predigested  protein  foods,  may  be  employed  in  bouillon,  or 
spread  on  bread  and  butter  sandwiches.  Fat  can  be  employed  in  the 
form  of  cream,  taken  on  the  breakfast  food,  freely,  in  tea  and  coffee, 
with  limitations  mentioned  later,  salted  on  baked  potato,  or  sweetened 
on  stale  bread,  but  not  drunk  except  diluted  largely  with  milk,  for  it 
often  causes  unpleasant  eructations.  Butter  may  also  be  employed, 
but  special  precautions  must  be  taken  that  it  is  not  in  the  slightest  de- 
gree rancid.  During  the  hyperacid  stage,  however,  coffee,  as  well  as 
pepper,  had  best  be  avoided.  Cocoa,  particularly  the  digestible 
variety,  is  better  adapted.  Where  constipation  is  present,  buttermilk 
prepared  with  lactone  tablets  (forty-eight  hours  in  winter  and  thirty- 
six  in  summer)  can  be  taken  to  advantage,  and  its  effect  increased  by 
adding  to  each  glass  a  tablespoonful  of  milk  sugar.  The  following 
articles  are  strictly  contraindicated :  salted,  smoked,  and  pickled  her- 
ring, caviar,  and  anchovy.  Sodium  chloride  undoubtedly  causes  the 
secretion  of  gastric  juice  in  small  doses,  but  suppresses  it  in  large,  ac- 
cording to  Bickel.  Food  had  best  be  taken  in  three  meals,  which  must 
never  be  hurried,  provided  that  motility  is  impaired.  These  general 
principles,  arranged  in  the  form  of  a  diet  list,  are  here  given  for  those 
cases  where  the  disease  has  advanced  to  marked  diminution  of  gastric 
secretion : 

DIET   LIST   IN   CHRONIC   GASTRITIS   WITH    DIMINISHED   SECRETION. 

On  rising. — A  cup  of  hot  beef  tea,  made  with  Liebig's  or  Armours' 
preparation. 

Breakfast. — A  glass  of  orange  or  grape  fruit  juice;  a  saucer  of 
some  well-cooked  cereal,  except  oatmeal,  with  middle  heavy  cream, 
but  no  sugar ;  soft  boiled  or  scrambled  eggs,  or  some  crisp  bacon  with 
a  baked  potato ;  plenty  of  toast  or  crisp  stale  rolls,  reheated,  well  but- 


ACUTE   AND   CHRONIC   GASTRITIS  303 

tered;  and  some  cocoa  or  broma  or  coffee,  with  cream,  but  no  sugar, 
though  saccharine  may  be  used  for  sweetening. 

Dinner. — Soup,  not  too  fat,  with  barley  or  rice;  Hamburger  steak, 
or  the  inside  of  Frankfurter  sausage,  or  fish  hash  or  meat  hash,  or 
minced  chicken  or  lean  ham;  mashed  potato,  squash  or  turnip,  cauli- 
flower cooked  with  cream,  chopped  spinach,  or  well-cooked  rice;  gela- 
tine flavored  with  fruit  juice,  or  cooked  or  canned  fruit,  without 
sugar,  but  with  cream;  rice,  tapioca,  sago,  or  bread  pudding;  a  little 
sherry,  or  whisky,  or  brandy  and  water,  to  be  taken  after  the  meal  is 
eaten  (sherry  wine  preferable).  Red  pepper  to  be  used  freely  on 
meat  or  fish  food. 

Supper. — Toast  or  stale  rolls,  with  butter,  cream  or  mild  factory 
cheese,  bowl  of  custard;  pigs'  feet  not  pickled,  or  picked  or  broiled 
fish,  with  the  exception  of  mackerel  or  halibut.  Wine,  whisky,  or 
brandy  and  water  after  meal. 

Avoid  all  iced  drinks  or  foods,  drinking  with  meals,  rapid  eating, 
eating  when  unduly  tired  (rest  ten  minutes  before  the  meal),  sweets, 
or  a  large  amount  of  fats  other  than  cream  and  butter.  All  food  is  to 
be  well  salted. 

Many  recommend  gastric  lavage,  with  sodium  bicarbonate  (10  grams 
to  the  liter)  or  liquor  antiseptics  alkalinus  (a  tablespoonful  to  a  quart) 
added  to  the  wash  water,  with  the  thought  of  removing  as  much  as 
possible  of  the  attached  mucus,  but  our  experience  offers  but  little 
hope  of  accomplishing  this  purpose  unless  there  is  stasis,  and  in  sec- 
ondary gastritides,  due  to  heart  lesions  and  emphysema,  the  process 
is  very  distressing  to  the  patient,  if  not  dangerous.  This  lavage  is 
best  carried  out  in  the  morning,  so  that  the  new  day  may  begin  with 
the  stomach  free  from  debris.  Both  in  the  superacid  and  anacid 
stages  of  the  disease,  mineral  waters  have  had  a  vogue.  For  the  former 
we  use  Carlsbad,  and  for  the  latter,  Kissingen,  both  found  in  the 
Newer  Formulary  and  made  artificially  by  the  pharmacist,  which  can 
be  taken  at  home ;  or,  for  the  people  of  means,  drinking  the  waters  at 
the  springs  adds  to  effecting  a  cure  the  special  advantages  mentioned 
in  Chapter  VIII  on  treatment.  In  inacid  gastritis  the  homely  remedy, 
of  drinking  a  half  teaspoonful  of  cooking  salt  in  a  cup  of  hot  water, 
sipped  slowly,  has  accomplished  much  in  controlling  the  early  morn- 
ing vomiting  of  the  chronic  toper ;  it  is  to  be  taken,  if  possible,  before 
rising.  When  the  gastric  secretion  is  impaired  or  suppressed,  the 
bath  spray,  alternating  between  extremely  hot  and  extremely  cold 
water,  and  applied  to  the  epigastrium,  aids  somewhat  in  arousing  a 


304  DISEASES   OF   THE   DIGESTIVE   TRACT 

flow  of  gastric  juice,  which  manifests  itself  by  an  increasing  appetite. 
Medical  treatment  consists  largely  in  trying  to  replace  the  lost  gastric 
juice  and  improving  the  motility  where  it  fails.  For  the  former  pur- 
pose, nothing  aids  more  than  10  drops  of  dilute  hydrochloric  acid 
taken  in  a  glass  of  water,  part  before  and  part  after  the  meal,  through 
a  tube.  For  the  well-to-do,  acidol  and  acidol  pepsin,  a  tablet  in  a  wine- 
glass of  water  after  each  meal,  works  well.  Another  advantage  of 
this  treatment  bears  repetition,  and  that  is  that  acid  medication  also 
arouses  the  pancreatic  juice,  which  must  vicariously  assume  a  part  of 
the  duties  of  the  stomach.  Where  it  is  found  after  a  time  that  the 
acid  has  not  returned  to  the  stomach,  a  trial  may  be  made  of  pan- 
ereatin  if  given  in  keratin  capsules  of  0.5  gram  just  before  a  meal,  but 
in  our  experience  it  is  difficult  to  obtain  more  than  0.06  gram  in  the 
stock  capsules,  as  druggists  are  averse  to  making  them  up.  Hence 
pankreon,  in  spite  of  its  cost  and  sometimes  the  difficulty  in  procuring 
it,  has  become  our  mainstay,  and  capsules  (0.5  gram)  given  just  be- 
fore meals  form  an  efficient  service.  On  account  of  the  lack  of  appe- 
tite, a  bitter  may  be  added  to  the  acid  to  advantage,  the  following 
prescription  is  to  be  recommended : 

IJ     Acidi  hydrochloridi  diluti, 

Tincturae   nucis   vomica?,   asl 15.0   or   %   ounce 

M.  Sig. :     Twenty  drops  in  a  glass  of  water  before  and  during  the 
meal  through  a  tube. 

Fluid  extract  of  condurango  may  also  be  tried  in  doses  up  to  a  tea- 
spoonful  in  water  before  meals,  but  arousing  an  appetite  by  means  of 
drugs  is  often  almost  a  hopeless  task.  AYhere  there  is  a  foul  breath, 
rinsing  the  mouth  every  morning  with  hydrogen  peroxide  often  allays 
the  difficulty  for  the  day.  Where  there  is  much  acid  eructation,  mag- 
nesium oxide  can  be  employed  as  a  powder  in  gram  doses.  As  the 
powder  is  harmless,  it  may  be  given  in  bulk  to  the  patient,  and  he  may 
take  enough  to  neutralize  the  acidity  of  his  stomach.  Pain  is  rarely 
a  prominent  feature,  but,  when  present,  can  be  controlled  by  anes- 
thesin,  in  doses  of  0.2  gram  (3  grains)  in  capsules  two  or  three  times 
per  day,  or  often  enough  to  keep  the  pain  under  control.  Patients 
must  be  fully  warned  against  the  use  of  laxatives,  and,  if  with  the 
diet  the  bowels  still  fail  to  move,  the  only  thing  that  can  be  allowed  is 
purified  liquid  petroleum  and  enemata. 


CHAPTER  X 

GASTRIC  ULCER 

The  causes  of  gastric  ulcer,  sometimes  called  peptic  and  round 
ulcer,  have  been  largely  discussed,  and  perhaps  three  have  been  fairly 
well  established: 

1.  Embolism  of  an  artery,  which,  because  it  is  a  terminal  one,  causes 
all  circulation  to  cease  and  allows  the  gastric  juice  to  digest  out  that 
part  to  which  the  terminal  arterioles  reach.  These  emboli  are  sup- 
posed to  be  caused  by  toxic  or  infectious  agencies  which  enter  the  cir- 
culation, as  sometimes  occurs  in  pyemia,  and  particularly  after  sev- 
eral large  burns  of  the  skin. 

2.  An  increased  amount  of  hydrochloric  acid  is  usually  found  in  the 
stomach  of  those  suffering  from  ulcer,  existing  as  a  hypersecretion, 
though  recently  this  excess  of  gastric  juice  has  been  regarded  as  a  re- 
sult of  ulcer  and  not  a  contributory  cause ;  nor  is  it  invariably  present, 
as  some  report  true  ulcers  with  diminished  or  even  absent  hydrochloric 
acid. 

3.  Small  hemorrhages  from  the  mucous  membrane  surface  of  the 
stomach,  caused  by  trauma,  by  the  irritation  of  articles  of  food  too  hot 
or  chemically  corrosive,  or  blood  vessels  ruptured  by  intense  vomit- 
ing. It  is  one  of  the  most  common  of  gastric  diseases,  and  is  found 
much  oftener  in  women  than  in  men,  usually  stated  in  a  ratio  of  2 :1. 
As  to  age,  ulcer  in  women  is  most  often  found  between  20  and  30, 
while  in  men  it  may  occur  between  30  and  50  years.  Under  10  years 
of  age.  children  are  rarely  found  to  have  ulcer.  The  disease  is  prev- 
alent in  those  regions  where  hypersecretion  is  more  common,  and 
that  usually  coincides  with  localities  where  the  use  of  meat  and  condi- 
ments prevails.  Occupation  was  supposed  to  play  some  part,  as  cooks 
were  mueli  oftener  attacked  than  others,  but  Zweig  has  pointed  out 
that  as  a  class  they  seek  the  hospitals  and  clinics  more  frequently  than 
any  other,  and  hence  swell  the  statistics.  Furthermore,  Cohnheim 
thinks  there  is  much  greater  prevalence  of  this  disease  in  cobblers, 
who  bend  to  their  work,  often  pressing  a  shoe  against  the  epigastrium 
as  they  ]abor.  Also  those  who  wear  belts  and  corsets  are  more  prone, 
as  a  class,  to  this  disease  on  account  of  the  constant  pressure  over  the 

305 


306  DISEASES   OF   THE   DIGESTIVE   TRACT 

upper  abdomen.  The  association  of  blows  with  the  origin  of  ulcer 
may  be  doubted  by  some,  but  very  intimate  relations  exist  in  some  in- 
stances, as  in  the  case  of  a  woman,  which  aroused  our  interest,  who 
was  thrown  against  a  car  seat  in  front  of  her,  striking  her  upper 
abdomen.  Vomiting  of  blood  followed  on  that  same  night  and  she 
rapidly  succumbed  to  gastric  ulcer.  The  reply  could  be  made  that 
she  had  the  disease  when  the  accident  happened,  but  this  is  hardly 
tenable  when  we  learn  that  no  gastric  symptoms  had  ever  occurred  be- 
fore the  accident.  From  the  circulatory  disturbances  come  the  often 
repeated  gastric  ulcers  of  the  arteriosclerotic  men  between  the  ages  of 
40  and  50.  In  chlorotic  girls,  suffering  from  habitus  enteropticus, 
the  vessels  are  very  narrow,  thus  predisposing  to  more  ready  occlusion 
and,  on  account  of  the  character  of  the  blood,  to  mucous  membrane 
necrosis.  This  is  still  further  emphasized  by  Stiller,  who  found  an 
unusual  frequency  in  the  combination  of  gastroptosis  and  ulcer  ex- 
plained by  the  narrowed  vessels  and  by  the  readiness  with  which 
a  ptosed  stomach  favors  mild  stasis  and  hypersecretion.  Another  fre- 
quent combination  is  ulcer  and  tuberculosis  for,  as  is  well  known,  the 
possessor  of  the  latter  disease  often  has  the  habitus  enteropticus  in 
its  most  exaggerated  form.  Of  noxious  substances  with  causative  in- 
fluence, we  may  mention  alcohol,  for  ulcer  is  especially  common  among 
chronic  drinkers,  particularly  those  in  our  mind  who  are  accustomed 
to  take  one  or  two  drinks  to  arouse  appetite.  Furthermore,  there  is 
such  a  close  association  between  extensive  burns  and  ulcer  that  we 
must  recognize  toxic  substances  produced  by  the  former  as  instru- 
mental in  inducing  the  latter.  There  can  be  but  little  doubt,  too,  that 
the  irritation  of  the  vagus  nerve,  a  condition  known  as  vagotonus,  may 
be  a  strong  causative  agency  in  arousing  ulcer.  Notwithstanding  a 
newer  compilation  of  statistics  shows  that  only  one-third  of  the  cases 
of  ulcer  have  hypersecretion,  it  behooves  us,  whenever  the  latter  is 
found,  to  look  carefully  for  an  ulcer,  since  many  a  case  of  long-drawn- 
out  hypersecretion  has  turned  out  to  be  associated  with  a  gastric  ulcer. 
For  years  we  have  been  demanding  either  copious  hematemesis  or 
gastric  stasis  to  make  the  diagnosis  of  ulcer,  while  now  we  are  begin- 
ning to  realize  that  the  hemorrhage  may  be  so  slight  as  to  deserve  the 
term  "occult,"  and  stasis  may  not  occur,  though  operation  shows 
well-marked  ulcer. 

Symptoms. — The  symptoms  are  varied  in  intensity  and  frequency, 
but  the  most  common  and  persistent  is  pain.  This  occurs  fifteen 
minutes  to  one  hour  after  food  is  taken,  is  burning  or  colicky,  and  is 
much  worse  after  solid  food  than  after  liquid.     Some  patients  declare 


GASTRIC  ULCER  307 

that  the  pain  is  worse  when  lying  on  the  right  side  than  on  the  left  or 
on  the  back;  some  insist  that  walking  brings  it  on,  but  it  ceases  on 
lying  down ;  while  others  declare  that  talking  rapidly  or  becoming  ex- 
cited by  increasing  the  excursions  of  the  diaphragm  aggravates  their 
distress.  The  pain  is  usually  localized  by  the  patient  just  below  the 
breast  bone,  but  may  be  under  the  sternum,  or  under  the  left  costal 
border  and  extend  to  the  left  scapula  region.  It  may  be  so  intense 
that  in  women  the  corset  must  be  removed  and  men  have  to  relieve  the 
pressure  of  their  belt  if  one  is  worn.  At  the  height  of  the  pain, 
vomiting  may  occur,  which  causes  the  attack  to  cease  for  the  time 
being;  the  vomitus  is  extremely  acid,  and  some  declare  corrodes  their 
teeth ;  blood  traces  may  be  found,  or  vomiting  may  sometimes  continue 
until  an  ejection  of  fresh  blood  may  occur,  or,  as  occasionally  happens, 
extensive  bleeding  takes  place  during  sleep  and  the  patient  is  aroused 
only  to  eject  a  large  quantity  of  reddish-brown,  partially  digested 
blood.  The  appetite  is  usually  retained;  in  fact,  may  be  so  excessive 
that ' '  ox  hunger ' '  results.  Usually,  however,  from  fear  of  pain,  little 
food  is  taken,  and  the  ulcer  patient  is  generally  very  thin,  almost 
emaciated.  The  bowels  are  usually  confined,  but  may  be  normal ;  the 
feces  often  contain  traces  of  digested  blood,  detected  only  by  chemical 
means;  less  often  the  tarry  stools  occur  where  hemorrhage  has  been 
copious.  It  is  stated  that  careful  chemical  examination  will  disclose 
traces  of  blood  in  the  stool  or  vomitus  in  30-74  per  cent  of  cases  of 
ulcer,  so  that  this  fact  forms  a  great  aid  to  the  diagnosis. 

Among  the  most  valuable  objective  symptoms  are  the  pressure 
points,  as  described  in  Chapter  III  under  Examination  of  the  Patient. 
The  epigastric  one  is  usually  the  most  circumscribed,  and  one  rarely 
fails  to  observe  the  look  of  pain  on  the  patient 's  face  when  it  is  pressed 
or  tapped  with  the  percussion  hammer.  The  dorsal  point  or  points 
are  not  so  well  restricted ;  in  fact,  Seidl,  in  a  careful  investigation  of 
the  subject,  learned  that  they  might  be  found  anywhere  from  the 
junction  of  the  tenth  to  the  second  rib  and  on  either  side  of  the  spinal 
column,  dependent  on  the  position  of  the  ulcer  in  the  stomach.  What 
he  did  emphasize  most  emphatically  was  their  aid  in  differentiating  be- 
tween functional  dyspepsia  and  true  ulcer.  The  cause  of  this  pres- 
sure point  has  never  been  fully  defined,  but,  since  the  mucous  mem- 
brane of  the  stomach  is  so  lacking  in  sensation,  a  perigastritis  at  the 
site  of  the  ulcer  will  explain  this  tenderness.  The  pain  experienced 
may,  of  course,  come  from  the  ulcer,  cholecystitis,  or  gastroptosis,  and 
one  of  our  most  difficult  duties  is  to  disentangle  the  jumble  of  symp- 
toms, some  related  and  some  not,  which  patients  pour  into  our  ears. 


308  DISEASES   OP   THE   DIGESTIVE   TRACT 

In  favor  of  ulcer  is  the  pain  after  eating,  more  severe  after  solid  than 
liquid  food ;  stronger  when  the  patient  is  on  his  feet  than  lying  down, 
occurring  daily  for  weeks,  and  the  stool  containing  chemical  blood. 
For  cholelithiasis  the  strongest  points  are  attacks  of  pain  at  night  or 
when  the  stomach  is  empty,  and  long  periods  of  complete  freedom 
from  discomfort;  pain,  in  the  classical  description,  starts  from  the 
right  costal  border  and  extends  to  the  back,  but  in  reality  it  is  often 
complained  of  in  the  median  line ;  enlarged  liver  and  icterus  are  pres- 
ent when  the  common  duct  is  occluded,  but  many  an  attack  pursues 
its  course  without  either,  for  the  stone  may  be  in  the  cystic,  or  there 
may  be  no  stone  whatever,  but  inspissated  bile  and  tenacious  mucus, 
which  cause  the  colic.  Food,  position,  or  exercise  have  no  influence 
on  the  attack.  Gastroptosis  as  a  cause  for  the  pain  is  indicated  by 
the  absence  of  influence  in  the  kind  of  food,  by  relief  when  the  patient 
lies  down,  or  when  the  abdomen  is  supported  by  a  well-fitting  belt, 
and  by  the  visible  pulsations  of  the  aorta,  as  well  as  by  the  absence  of 
blood  in  the  feces.  It  has  been  stated  that  the  presence  of  a  pressure 
point  at  the  right  of  the  spinal  column,  at  the  level  of  the  tenth  to 
twelfth  rib,  speaks  for  cholelithiasis,  but  the  findings  of  Seidl,  men- 
tioned above,  rather  shatter  this  distinction.  "Occult"  blood  can  be 
found  in  the  gastric  contents,  but,  as  mentioned,  on  account  of  the 
ease  with  which  the  tube  may  cause  small  erosions  with  bleeding,  one 
should  always  rely  on  the  stool  for  this  test.  An  excessive  percentage 
of  hydrochloric  acid  in  gastric  contents  has  onlj^  a  limited  significance 
in  ulcer,  but  a  continuous  secretion — that  is,  the  findings  of  50  c.c.  or 
more  of  almost  pure  gastric  juice  in  the  fasting  stomach — with  a  high 
hydrochloric  acid  content  (40  and  more  is  not  uncommon  in  our  expe- 
rience), is  most  suggestive  of  ulcer.  Hypersecretion  determined  in 
this  way  is  almost  invariably  the  consequence  of  the  ulcer  when  no 
food  fragments  are  present.  The  detection  of  microscopic  stasis  after 
an  evening  Eiegel  meal  has  proved  less  reliable  in  our  hands,  and, 
when  operation  has  been  undertaken  for  ulcer  based  on  this  and  the 
increased  acidity  due  to  hydrochloric  acid  after  the  test  breakfast, 
the  surgeon  has  reported  no  lesion.  Theoretically,  when  the  ulcer  has 
cicatrized,  the  stomach  wall  at  the  site  has  lost  partially  its  motility 
and  slight  stasis  follows.  Strauss  gives  2  grams  of  bismuth  and  looks 
for  the  retention  of  some  of  it  in  the  wash  water,  and  Kaufman  puts 
much  dependence  on  the  absence  of  mucus  in  the  gastric  contents.  In 
our  opinion  the  presence  of  bile  in  the  contents  after  a  test  breakfast, 
but  not  in  the  fasting  stomach,  is  very  significant  of  chronic  ulcer 
at  the  pylorus,  because  the  latter  does  not  close  completely  under  these 


GASTRIC  ULCER  309 

conditions.  Among  the  general  symptoms  which  attract  attention  are 
the  evidences  of  anemia  and  emaciation,  the  result  of  insufficient 
nutrition  and  minute  hemorrhages  from  the  lesion.  The  long  suf- 
fering, too,  from  the  ulcer  produces  a  chain  of  neurasthenic  symptoms, 
so  that  it  is  often  difficult  to  separate  the  organic  disease  from  a  func- 
tional dyspepsia.  These  nervous  symptoms  also  persist  a  long  time 
after  an  operation  for  ulcer,  and  often  cause  the  physician  to  despair 
of  relief  to  the  patient,  but  later  the  former  regains  his  nervous  tone. 

One  of  the  most  common  complications  is  gastric  dilatation,  which 
may  be  variable  when  largely  due  to  pyloric  spasm,  so  that  retention 
may  be  found  over  a  longer  or  shorter  period,  after  which  it  disap- 
pears under  treatment.  AVhether  the  ulcer  at  the  pylorus  really  heals 
is  difficult  to  say,  but  at  least  the  relief  is  not  permanent,  and  sooner 
or  later  stasis  recurs;  or  there  may  result  actual  stenosis  from  scar 
tissue,  when  gastric  dilatation  and  stasis  become  steadily  progressive 
until  visible  peristalsis  of  the  stomach  can  be  seen  through  the  ab- 
dominal wall  after  every  meal. 

Another  common  complication  is  perigastritis,  an  extension  of  the 
ulcer  to  the  peritoneum  and  the  union  of  the  stomach  with  other 
organs.  These  adhesions  produce  the  most  bizarre  symptoms,  boring 
sensations  deep  in  the  abdomen,  cardialgia  after  a  full  meal,  pain  in 
the  epigastric  region  just  before  or  during  stool,  and  sharp  pain  with 
rapid  and  deep  inspiration.  Unless  some  marked  anomaly  in  the  per- 
cussion outline  of  the  stomach  is  discovered,  a  diagnosis  can  be  made 
only  by  exclusion.  Strange  to  say,  relief  can  sometimes  be  obtained 
by  gastroenterostomy,  when  adhesions  themselves  are  undisturbed. 

The  most  dangerous  of  all  symptoms  is  a  perforation,  by  which  the 
peritoneal  cavity  is  filled  with  gastric  contents  and  blood  clots.  This 
may  sometimes  happen,  as  surgeons  at  hospitals  who  do  much  emer- 
gency work  assure  us,  without  the  slightest  warning  in  the  way  of 
previous  symptoms.  The  patient  is  in  agony,  complaining  that 
something  is  tearing  his  abdomen,  the  face  is  drawn  and  pinched, 
the  temperature  is  subnormal,  and  collapse  ushers  in  the  fatal  termi- 
nation. Vomiting  is  rare,  the  abdomen  is  canoe-shaped,  the  region  of 
the  epigastrium  hard  and  rigid,  liver  and  spleen  dullness  are  obliter- 
ated, and  soon  fluid  begins  to  accumulate  in  the  dependent  portions 
of  the  abdomen  if  the  victim  lives  long  enough.  "WTien  adhesions  have 
taken  place  previous  to  the  rupture,  the  general  peritoneum  is  pro- 
tected, and  often  a  well-circumscribed  cavity  is  found  containing  the 
same  elements  which  sometimes  become  purulent.  If  the  perforation 
is  into  a  neighboring  organ  (liver  or  pancreas),  that  may  become  par- 


310  DISEASES   OF   THE   DIGESTIVE   TRACT 

tially  digested,  and  the  x-ray  will  show  an  indentation  filled  with  bis- 
muth after  the  Rieder  meal.  Fortunately,  fatal  hemorrhages  are  only 
rarely  complications  of  ulcer,  and  occur  in  about  1  per  cent  of  the 
cases  under  observation.  Generally,  there  occurs  only  a  moderate 
hemorrhage,  which  stops  of  itself,  and  the  patient  recovers  rapidly 
from  the  great  loss  of  blood;  still,  cases  do  occur  of  severe  hemor- 
rhage which  demand  operative  intervention.  Rarely  a  chronic  ulcer 
leads  to  the  formation  of  scar  tissue  which  can  be  detected  by  palpa- 
tion. Such  ulcer  tumors  (if  we  may  call  them  so)  are  often  very  dif- 
ficult to  distinguish  from  a  carcinoma.  If  the  tumor  persists  longer 
than  three  years,  and  if  free  hydrochloric  acid  can  be  discovered,  this 
speaks  distinctly  for  a  benign  tumor.  Perigastric  adhesions  and 
spasm  of  the  pylorus  are  also  felt  as  rigid  tumors,  though  such  an 
event  is  of  rare  occurrence. 

A  much  rarer  complication  of  ulcer  is  the  hourglass  stomach,  which 
arises  from  an  ulcer  lying  between  the  cardia  and  the  pylorus,  whose 
scar  by  contraction  divides  the  stomach  into  two  parts.  The  diag- 
nosis of  the  hourglass  stomach  is  extremely  difficult.  Sometimes  we 
may  detect  it  by  the  peculiar  percussion  outline  of  the  inflated 
stomach ;  at  other  times,  when  w^e  imagine  that  we  have  entirely 
emptied  the  stomach  with  lavage,  there  will  come  a  gush  of  fluid 
heavily  loaded  with  food  fragments.  Of  course  the  surest  way  to 
diagnose  this  condition  is  by  means  of  the  x-ray. 

The  most  important,  however,  is  the  part  that  chronic  ulcer  plays 
in  the  causation  of  carcinoma.  The  diagnosis  can  often  be  made  after 
long  observation  and  frequent  examination  of  the  gastric  contents.  A 
carcinoma  which  has  its  site  upon  an  ulcer  scar  is  distinguished  by 
the  fact  that  for  a  long  period  free  hydrochloric  acid  can  be  detected, 
though  the  amount  grows  steadily  less  and  less  with  the  growth  of 
the  carcinoma  until  it  finally  entirely  disappears  in  order  to  give  way 
to  a  large  amount  of  lactic  acid,  which  then  firmly  establishes  the 
diagnosis.  There  occurs  to  us  at  least  one  case  in  which  free  hydro- 
chloric acid  and  sarcinae  ventriculi  persisted  for  a  long  time,  the  latter 
also  readily  discoverable  in  the  feces,  but  eventually  the  hydrochloric 
acid  disappeared,  while  the  same  vegetation  was  found  with  scanty 
lactic  acid  bacilli,  which,  in  turn,  gave  way  to  an  abundant  growth  of 
the  latter  bacilli.  It  was  only  by  a  successive  series  of  the  examination 
of  gastric  contents  that  this  chain,  from  what  was  apparently  first  be- 
nign to  what  an  autopsy  proved  to  be  malignant,  was  followed. 

Treatment. — The  treatment  of  ulcer  can  begin  only  after  the  affec- 


GASTRIC  ULCER  311 

tion  is  established,  since,  as  we  do  not  know  its  cause,  we  can  offer 
no  suggestions  as  to  prevention.  Still,  we  may  do  something  to  avoid 
it  by  paying  attention  to  those  conditions  which  accompany  it,  even 
if  we  cannot  prove  them  to  be  its  cause.  Among  these  means  belongs, 
before  all,  the  control  of  the  hypersecretion,  which,  as  stated,  inter- 
feres very  emphatically  with  the  healing  of  the  ulcer.  At  the  same 
time  we  must  also  oppose  vigorously  chlorosis  and  anemia,  since  these 
two  conditions  furnish  very  disadvantageous  features  for  the  control 
of  the  lesion.  Here,  however,  we  have  to  stop  and  acknowledge  that 
there  is  nothing  else  that  we  can  do  to  prevent  an  ulcer.  In  real 
treatment  we  are  dealing  with  three  different  conditions,  which  de- 
mand, of  course,  distinct  forms  of  treatment :  1,  hemorrhagic  stage, 
which  may  be  regarded  as  its  acute  form;  2,  the  conditions  present 
in  chronic  ulcer;  3,  the  complications  and  results  of  the  chronic 
form. 

1.  The  hemorrhagic  stage,  or  dcute  gastric  ulcer,  demands  absolute 
rest  in  bed  for  the  patient,  as  well  as  prevention  of  any  extensive  mo- 
tion, as  leaving  the  bed,  or  even  rising  to  an  erect  position  for  the 
purpose  of  passing  the  stool  or  urine.  All  friends  and  visitors  must 
be  absolutely  forbidden  to  talk  with  the  patient,  since  all  forms  of 
mental  excitement  are  liable  to  increase  the  blood  pressure  and  aggra- 
vate the  condition.  All  forms  of  nutriment  by  the  mouth  are  to  be 
strongly  forbidden,  and  even  lumps  of  ice,  which  have  proved  so 
gratifying  to  the  patient,  must  not  be  allowed,  so  that  the  damaged 
organ  may  be  kept  in  a  state  of  absolute  rest.  All  medicinal  treat- 
ment by  the  mouth  must  be  avoided,  since  the  absolute  freedom  from 
any  material  in  the  organ  is  the  best  styptic.  Through  these  means 
alone  it  is  usually  possible  to  check  the  hemorrhages  within  the  first 
twenty-four  hours.  If  this  does  not  take  place,  then  we  may  make 
use  of  certain  medicaments  which  have  a  reputation  for  checking 
hemorrhage.  The  best  of  these  is  a  preparation  of  ergot  or  ergotine, 
which  can  be  used  hypodermatically.  A  form  is  put  up  under  the 
title  of  "ergot  aseptic"  in  ampules,  which  contain  1  c.c,  an  average 
dose,  are  sterilized,  and  can  be  used  directly  in  the  hypodermic  syr- 
inge. This  can  be  repeated  once  in  an  interval  of  two  hours  in  case 
the  hemorrhage  does  not  cease.  In  recent  times  gelatine  has  also  been 
employed  for  a  hemostatic,  and,  provided  that  it  is  properly  sterilized 
(on  account  of  the  unfortunate  fact  that  tetanus  bacilli  have  been 
found  in  it),  can  also  be  injected  directly  by  means  of  the  subcutaneous 
syringe.     The  usual  preparation  is  as  follows: 


312  DISEASES   OF   THE   DIGESTIVE   TRACT 

IJ     Gelatinae   1.0-2.0  grams  or  y^-\^  dram 

Sodii  chloridi    0.6  gram  or  10  grains 

Aquae  sterilizatae    100.0  c.c.  or  3  ounces 

M.  Sig. :     For  hypodermic  injection. 

Of  this  1  to  2  per  cent  gelatine  solution,  80-100  c.c.  are  to  be  warmed 
to  body  temperature  and  then  injected  by  means  of  an  antitoxin 
syringe  under  the  skin  of  the  abdomen.  These  injections  are  some- 
what painful,  and  are  not,  as  stated,  entirely  free  from  the  danger  of 
tetanus  infection.  Much  less  harmful  is  the  use  of  a  20  per  cent  solu- 
tion of  gelatina  sterilizata,  which  can  be  employed  hypodermatically, 
and  can  be  used  by  rectal  injections  in  concentration  of  5  per  cent 
to  10  per  cent  and  in  amounts  of  200  c.c.  This  latter  method  of  em- 
ployment has  proved  very  satisfactory  to  us,  and  no  case  has  yet  arisen 
where  its  hypodermatic  use  was  found  necessary.  A  more  recent 
remedy,  which  may  be  employed  as  a  hemostatic  and  has  given  satis- 
faction, is  adrenalin  in  1 :10,000  solution,  put  up  in  ampules  containing 
the  exact  dosage  of  1  c.c,  which  is  to  be  injected  with  a  syringe.  An 
injection  may  be  given  daily,  or  we  may  add  30  drops  of  the  solution 
to  the  nutrient  enema,  or  it  may  be  given  by  the  mouth.  From  the 
adrenalin  alone  results  have  not  been  so  brilliant,  but  as  an  addition  to 
the  physiologic  salt  solution,  which  should  always  be  injected  where 
much  loss  of  blood  has  occurred,  it  has  proved  very  efficacious  in  in- 
creasing the  blood  pressure  and  checking  the  condition  of  collapse. 
Enemata  of  ice  water  also  prove  very  satisfactory,  since  they  re- 
flexly  produce  contractions  of  the  stomach  and  its  vessels.  Boas' 
suggestion  that  one  give  an  enema  of  10-20  c.c.  of  a  10-20  per  cent 
calcium  chloride  solution  is  a  good  one  and  will  often  prove  efficacious, 
but  in  the  most  obstinate  cases  (luckily  few  in  number)  the  gelatine 
solution  employed  hypodermatically  is  the  last  resort.  ]\Iucli  less 
dangerous  is  the  use  of  gelatine  by  the  mouth,  which  is  also  very  effec- 
tive. One  should  give  the  patient  a  tablespoonful  of  a  10  per  cent 
solution,  to  which  10  per  cent  of  cane  sugar  may  also  be  added.  The 
gelatine  causes  thrombosis  of  the  small  vessels  and  thereby  cheeks  the 
bleeding.  Very  often  the  pain  and  uneasiness  of  the  patient,  which 
cause  him  to  toss  about,  an  act  in  itself  provocative  of  increased 
bleeding,  must  be  checked  by  a  hypodermatic  of  morphine  to  which 
atropine  has  been  added.  The  soluble  hypodermic  tablets  containing 
morphine  sulphate,  0.015  gram  (%  grain),  and  atropine  sulphate, 
0.0005  gram  (M20  grain),  are  most  convenient  for  use.  It  is  true  that 
morphine  increases  the  secretion,  but  the  atropine  usually  holds  tliis 
action  in  check.     Codeine  phosphate,  which  does  not  possess  this  dis- 


GASTRIC  ULCER  313 

advantage,  also  will  quiet  the  pain  and  the  patient,  but  is  not  so  ef- 
fective as  morphine.  This  also  may  be  given  by  hypodermatic  injec- 
tion in  doses  of  0.03  gram  (^o  grain),  and  can,  of  course,  be  repeated 
oftener  than  the  morphine;  or  suppositories  of  extract  of  belladonna, 
0.010-0.020  gram  (%-/4  grain),  may  be  given.  If  collapse  seems 
imminent,  subcutaneous  injections  of  sterilized  0.6  per  cent  salt  solu- 
tion should  be  made  in  the  buttocks,  and  in  some  cases  1^  liters  were 
introduced  in  this  way  by  a  Potain  or  antitoxin  syringe  without  much 
discomfort.  This  amount  has  been  taken  up  with  surprising  rapidity 
by  the  circulation,  with  immediate  benefit  to  the  patient,  as  shown  by 
the  cessation  of  the  sighing  respiration  and  the  return  of  color  to  the 
blanched  face.  On  the  second  day  after  the  hemorrhage  it  is  pos- 
sible to  begin  the  rectal  enemata  (page  261),  forbidding  the  patient 
to  make  any  voluntary  motion  whatever.  At  first  three  nutrient 
rectal  injections  and  one  of  water  for  thirst  will  be  sufficient ;  the 
latter  should  consist  of  100  c.c.  of  beef  broth,  100  c.c.  of  50  per  cent 
cane  sugar  solution,  and  10  drops  of  tincture  of  opium.  This  injec- 
tion leaves  no  residue  in  the  rectum,  being  fully  absorbed,  and 
quenches  the  thirst  better  than  anything  else  suggested.  All  forms  of 
alcohol  are  to  be  rejected,  for  it  has  been  determined  that  all  solutions 
containing  7-10  per  cent  of  alcohol,  when  introduced  into  the  rectum, 
increase  the  gastric  secretion.  These  rectal  injections  should  be  con- 
tinvied  from  eight  to  ten  days  after  the  hemorrhage  ceases  before  we 
proceed  to  feeding  by  mouth.  In  the  meantime  a  light  ice  bag  should 
be  placed  over  the  epigastrium;  it  relieves  the  pain,  even  if  it  has  no 
action  on  the  bleeding.  Warm  applications  should  not  be  applied  to 
the  abdomen  for  a  long  period  after  the  bleeding  ceases. 

2.  The  second  stage,  or  chronic  ulcer.  P'ormerly,  by  adhering 
closely  to  Leube's  rigid  diet,  very  often  the  ulcer  was  cured,  but  the 
patient  was  reduced  to  a  state  of  emaciation,  as  in  typhoid  fever. 
Now,  however,  it  has  been  found  that  the  Lenhartz  diet,  which  affords 
vastly  more  nutriment,  since  more  concentrated,  leaves  our  patients  in 
a  much  better  condition  and  undoubtedly  hastens  the  cure,  because 
naturally  a  healing  process  will  take  place  much  more  readily  when  a 
patient  is  in  the  best  possible  condition,  and  no  harm  has  as  yet  come 
from  this  more  liberal  feeding.  The  first  essential,  however,  is  rest  in 
bed.  The  treatment  should  not  be  begun  for  at  least  eight  days  after 
a  hemorrhage  and  should  continue  from  four  to  six  weeks. 

During  the  first  week  the  diet  must  consist  largely  of  milk,  since  it 
will  combine  and  neutralize  a  large  amount  of  acid,  is  nonirritating, 
and  furnishes  but  little  salt  from  which  the  economy  can  make  acid. 


314  DISEASES   OP   THE   DIGESTIVE   TRACT 

It  is  better  to  cook  the  milk,  remove  the  scum  which  rises  to  the  top, 
and  then  give  it  cool  or  lukewarm,  but  never  ice  cold.  As,  unfor- 
tunately, 3  quarts  (3,000  c.c.)  of  the  milk  must  be  taken  per  day  to 
supply  the  needs  of  the  body,  it  has  been  found  necessary  to  fortify 
the  milk,  which  can  be  done  by  the  addition  of  flour  or  well-cooked 
Indian  meal,  1-2  tablespoonfuls  to  the  cup,  making  a  nutritious  gruel ; 
or,  what  is  somewhat  more  convenient,  the  addition  of  a  tablespoonful 
of  laibose  or  somatose.  If  the  patient  has  diarrhea,  we  may  add  % 
the  volume  of  lime  water  to  the  milk,  of  which  the  patient  is  not  to 
take  more  than  a  cupful  at  a  time.  In  addition,  one  can  give  2  table- 
spoonfuls  of  gelatine,  with  cream  and  sugar,  twice  daily,  as  well  as 
egg  yolks ;  the  egg  yolks  are  to  be  increased  one  daily  until  at  the  end 
of  the  week  five  are  taken,  and  may  be  beaten  and  drunk  sweetened,  or 
simply  thoroughly  mixed  with  the  milk.  Very  rarely  a  patient  is 
found  who,  on  account  of  diarrhea,  gaseous  distentions,  and  other 
evils,  cannot  take  milk  at  all.  Such  a  one  can  take  three  times  per 
day  a  cup  of  thickened  soup  made  of  chicken  broth,  1  tablespoonful 
of  sifted  flour,  2  tablespoonfuls  of  butter,  and  the  yolk  of  an  egg. 
By  means  of  such  a  form  of  nutriment  we  can  fully  supply  the  needs 
of  the  patient  during  the  first  week  without  having  recourse  to  milk. 
To  quench  the  thirst,  which  is  always  persistent,  we  may  use  albumen 
water.  This  is  prepared  by  adding  the  white  of  an  egg,  of  which,  of 
course,  the  yolk  may  be  used  in  the  milk  as  described,  to  a  cup  of 
fresh  or  cooked  water  after  cooling  and  thoroughly  stirring,  to  which 
4  teapsoonfuls  of  sugar  are  to  be  added.  Certain  mineral  waters  also 
fulfill  this  purpose  admirably,  such  as  contain  very  little  carbon 
dioxide,  of  which  the  best  is  Vichy,  easily  procured  at  any  drug  store. 

During  the  second  week  the  diet  should  remain  the  same  as  in  the 
first,  with  the  addition  of  only  some  zwieback  or  well-toasted  stale 
bread.  During  the  early  part  of  the  second  week  the  zwieback  had 
best  be  cooked  in  the  milk ;  later  it  can  be  eaten  as  obtained.  It  is 
best  to  begin  with  two  pieces  daily,  and  gradually  increase  one  piece 
each  day  until  at  the  end  of  a  week  five  pieces  are  taken. 

During  the  third  week,  as  soon  as  spontaneous  pain  or  pain  on 
pressure  has  ceased,  we  may  begin  with  a  meat  diet.  One  should  first 
give  about  3  ounces  of  well-chopped  or  ground  chicken,  squab,  or 
calves'  brain.  In  the  preparation  of  the  calves'  brain,  most  of  the 
connective  tissue  which  surrounds  the  brain  matter  should  be  care- 
fully removed,  and  the  remainder  cooked  lightly  in  butter,  or  made 
up  into  a  broth,  to  which  flour  may  be  added.  The  chicken  or  veal 
should  be  passed  through  a  meat  grinder,  and  then  cooked  and  served 


GASTRIC  ULCER  315 

as  bouillon.  It  is  much  better  during  the  first  week  to  give  as  little 
salt  as  possible,  and,  even  later,  salt  should  be  used  only  in  very  limited 
quantities  as  an  ingredient  of  the  food  served.  When  the  meat  causes 
no  discomfort,  on  the  next  day  the  same  amount  may  be  given  twice, 
and  this  may  be  continued  to  the  end  of  the  treatment.  In  addition 
to  this,  the  food  given  during  the  second  week  should  be  continued  as 
to  variety  and  quantity.  The  zwieback  may,  however,  be  spread 
thickly  with  butter,  and  butter  may  also  be  added  to  the  eggs. 

During  the  fourth  week  we  may  add  to  the  dietary  finely  chopped 
beefsteak  (from  the  tenderloin),  a  little  fresh  salmon,  venison  (if  it 
can  be  procured),  finely  chopped  roast  beef,  and  veal.  Fish  may  be 
added  to  the  dietary  in  the  form  of  cod,  haddock,  and  trout,  best 
broiled  and  well  spread  with  butter.  Of  vegetables,  spinach,  squash, 
and  mashed  potato,  in  which  butter  should  be  freely  used,  can  be 
added.  Fruit  in  the  form  of  applesauce  or  prune  whip  may  also  be 
employed. 

During  the  fifth  week,  in  addition  to  the  articles  of  food  already 
mentioned,  we  may  employ  omelet,  soft  boiled  eggs,  all  vegetables 
which  can  be  served  in  puree  form,  and  the  interior  of  rolls. 

After  two  months  we  may  give  meat  in  its  natural  form  (un- 
chopped),  the  diet  otherwise  remaining  the  same.  For  at  least  a 
year  one  must  forbid  raw  fruit,  all  vegetables  with  hulls,  ice  cream, 
all  very  hot  or  very  cold  drinks,  all  alcohol  in  concentrated  form 
(whisky,  brandy),  black  coffee,  sharp  condiments,  mustard,  brown 
bread,  or  graham  bread.  During  the  first  year  also  the  patients  must 
refrain  from  all  strenuous  bodily  exercise  which  brings  a  strain  upon 
the  abdominal  muscles  or  associated  with  pressure  upon  the  same. 
Among  this  group  belong  the  raising  of  heavy  burdens,  the  wearing 
of  a  belt,  riding,  rowing,  swimming,  and  gymnastics.  As  Oliver 
Wendell  Holmes,  in  his  "One-Hoss  Shay,"  remarks,  "there  is  always 
somewhere  a  weakest  spot."  We  must  convince  the  patient  that  his 
"weakest  spot"  is  the  site  of  the  ulcer  in  the  stomach,  and  that  it  is 
absolutely  necessary  that  he  should  avoid  any  strain  on  that  part  of 
his  body.  This  diet,  which  has  been  described  in  full,  has  been  sum- 
marized for  the  benefit  of  those  who  would  employ  it,  and  is  presented 
in  the  following  diet  list : 

DIET   LIST   FOR   GASTRIC    ULCER    (MODIFIED  LENHARTZ). 

It  is  absolutely  necessary  that  the  patient  be  kept  in  bed. 
7   a.   m. — A   half   glass   of   cooked   milk,   with   the   leathery   sub- 
stance which  rises  to  the  top  removed,  and  the  yolk  of  one  e^g  stirred 


316  DISEASES  OF   THE   DIGESTIVE   TRACT 

into  it  and  sweetened,  if  desired;  taken  lukewarm  or  cool,  but  never 
ice  cold.  This  amount  to  be  increased  on  the  second  day  to  three- 
fourths  of  a  glass,  and  on  the  third  to  a  full  glass,  which  is  to  be  con- 
tinued for  the  week.  If  the  milk  produces  diarrhea,  add  2  table- 
spoonfuls  of  lime  water  to  each  portion. 

9  a.  m. — A  saucerful  of  gelatine  (Knox's  or  Crystal  Rock),  with  2 
tablespoonfuls  of  cream  and  a  teaspoonful  of  sugar. 

12  m. — A  half  to  a  full  glass  of  milk  prepared  as  at  7  a.  m.,  with  a 
tablespoonful  of  laibose. 

3  p.  m. — A  saucerful  of  gelatine,  with  cream  (medium)  and  sugar, 
as  at  9  A.  M. 

6  p;  m. — A  half  to  a  whole  glass  of  milk,  as  before,  with  one  egg 
yolk  stirred  in  and  sweetened.  The  egg  yolks  at  7  a.  m.  and  6  p.  m. 
are  to  be  increased  until  six  are  taken  daily  at  the  end  of  the  week. 

8  p.  m. — A  half  to  a  full  glass  of  milk,  with  a  tablespoonful  of  lai- 
bose. 

The  whites  of  the  eggs  are  to  be  stirred  up  in  water  in  the  propor- 
tion of  a  white  to  a  glass  of  water,  4  teaspoonfuls  of  sugar  to  be 
added  to  every  glass,  and  only  this  to  be  taken  by  the  patient  when 
thirsty.  If  the  bowels  do  not  move,  no  laxatives  can  be  taken,  but  an 
injection  of  warm  water  or  a  little  soap  may  be  employed.  If  much 
discomfort  is  produced  by  the  food,  a  hot  compress  must  be  laid  over 
the  abdomen,  particularly  over  the  stomach  or  above  the  navel. 

This  has  been  modified  to  a  certain  extent  from  the  original  Len- 
hartz  in  order  to  make  it  more  acceptable  to  our  American  clientele. 
In  its  original  form,  the  Lenhartz  diet  contains  vastly  more  nourish- 
ment than  was  formerly  considered  advisable  in  the  treatment  of  ulcer. 
He  recommends  a  diet  very  rich  in  albumen  in  order  to  prevent  under- 
nourishment and  at  the  same  time  to  overcome  the  hyperacidity.  In 
general,  his  method  of  treatment  is  the  following: 

The  patient  must  remain  absolutely  quiet  in  bed  for  a  period  of 
four  weeks,  and  an  ice  bag  is  to  remain  constantly  upon  the  abdomen. 
On  the  day  of  the  hemorrhage  the  patient  is  to  receive  boiled  milk  in 
tablespoonful  doses  amounting  to  a  cupful,  as  well  as  one  to  three 
well-beaten  fresh  eggs,  during  the  first  twenty-four  hours.  Bismuth 
subnitrate  or  subcarbonate  in  2-gram  doses  is  to  be  given  two  to  three 
times  daily  suspended  in  water.  On  the  second  day  after  the  hemor- 
rhage, raw  eggs,  w^hich  have  been  well  beaten  and  cooled  in  a  refriger- 
ator, are  to  be  taken  slowly.  The  amount  of  milk  is  to  be  increased 
daily  by  3  ounces,  and  one  more  egg  is  to  be  added,  so  that  at  the  end 
of  the  first  week  %  liter  of  milk  and  six  to  eight  eggs  are  to  be 


GASTRIC   ULCER 


317 


taken  daily.  In  the  period  following  not  more  than  1  liter  milk  is 
to  be  given  per  day  in  order  to  prevent  an  overdistention  of  the 
stomach.  From  the  third  to  the  eighth  day  after  the  last  evidence 
of  bleeding,  finely  chopped  or  ground  raw  beefsteak  is  to  be  given  in 
amounts  of  1  ounce  per  day,  in  divided  portions,  mixed  with  the 
egg,  w^hich  is  to  be  gradually  increased  until  2  ounces  are  taken  daily. 
After  two  weeks  the  patient  is  to  receive  well-cooked  rice  and  softened 
zwieback  in  addition  to  the  continued  albuminous  food,  and  after  three 
or  four  weeks  a  sufficiently  mixed  diet  is  to  be  given,  although  it  is 
best  to  still  measure  accurately.  The  meat  need  no  longer  be  given 
raw,  but  may  be  lightly  broiled  or  well  boiled,  and  of  the  vegetable 
group  only  those  producing  much  gas  and  the  fruits  with  skins  need 
be  avoided.  Six  to  eight  hours  after  the  hemorrhage  Blaud's  pills, 
which  have  been  finely  powdered,  are  to  be  given.  The  following 
table  will  give  in  condensed  form  the  above  suggested  diet  list  and  the 
amounts  of  each  food : 


LENHARTZ   ULCER  DIET. 


Nutriment. 

Days  after  the  hemorrhage. 

Eggs     

Sugar  added  to  egg. 

Milk    

Raw  chopped  meat . . 
Well-boiled  rice    .... 

Zwieback    

Raw  ham 

Butter     

1 
2' 

200 

2 
3 

300 

3 

4 

20 

400 

4 

5 

20 

500 

5 

6 

30 

600 

6 
7 

30 
700 

35 

7 
8 
40  grams 
800  c.c. 
2X35  grams 
100  grams 

Calories     

280 

420 

637 

777 

955 

1135 

1588 

Nutriment. 

Days  after  the  hemorrhage. 

EffETS     

8 

8 

40 

900 

2X35 

100 

20 

9 

8 

50 

IL 

2X35 

200 

40 

10 

8 

50 

IL 

2X35 

200 

40 

50 

20 

11 

8 

50 

IL 

2X35 

300 

60 

50 

40 

12 

8 

50 

IL 

2X35 

300 

60 

50 

40 

13 

8 

50 

IL 

2X35 

300 

80 

50 

40 

14 

8 

Sugar  added  to  egg. . 

Milk    

Raw  chopped  meat.  . 
Well-boiled  rice    .... 
Zwieback    

50  grams 

IL 
2X35  grams 
400  grams 
100  grams 

50  grams 

40  grams 

Raw  ham   

Butter     

Calories    

1721 

2138 

2478 

2941 

2941 

3007 

3073 

318  DISEASES   OP   THE   DIGESTIVE   TRACT 

It  is  very  difficult  to  judge  the  actually  favorable  reports  given  of 
the  efficacy  of  the  Lenhartz  method  of  treatment,  since  cases  vary  so 
greatly  in  their  character.  It  is  undoubtedly  true,  however,  that  a 
more  generous  diet  after  a  hemorrhage  adds  very  much  to  the  rapidity 
of  the  healing  of  the  ulcer,  as  the  anemia,  which  is  the  greatest  ob- 
struction to  rapid  cicatrization,  is  more  quickly  overcome.  Still,  we 
must  recognize  that  the  ingestion  of  meat  on  the  sixth  day  after  a 
hemorrhage  is  a  rather  hazardous  procedure,  which  few  physicians 
will  dare  to  risk.  Others  who  have  employed  this  method  have  come 
to  the  conclusion  that  with  hemorrhage  the  simpler  diet  of  milk,  egg, 
and  gelatine,  which  has  been  given,  is  much  more  desirable,  while  in 
ulcer  without  hemorrhage  the  Lenhartz  diet  can  be  safely  followed 
and  very  often  with  brilliant  results.  Senator  recommends  gela- 
tine most  highly  for  the  nourishment  of  the  ulcer  patient,,  which,  in 
addition  to  possessing  a  high  nutritive  value,  tends  to  check  the  hemor- 
rhage. He  recommends  a  liquid  solution  of  pure  gelatine,  containing 
15  to  20  grams  of  the  substance  suspended  in  150  to  200  c.c.  of  water, 
to  which  some  lemon  juice  has  been  added,  and  which  is  to  be  warmed 
before  it  is  used.  Every  hour  or  two,  and  in  urgent  cases  every  fifteen 
to  thirty  minutes,  1  tablespoonful  of  this  is  to  be  given.  In  addition, 
fresh  butter  (mthout  salt)  and  cream  are  to  be  given  in  small  quanti- 
ties, but  often,  so  that  even  the  most  sensitive  individuals  will  receive 
in  the  course  of  a  day  an  ounce  of  butter  and  at  least  a  half  pint 
of  cream.  When  the  butter  is  not  taken  readily  by  the  patient,  it 
may  be  given  in  frozen  balls  without  distaste,  and  in  the  same  way 
the  cream  is  often  taken  much  more  easily  when  frozen,  either  with 
or  without  sugar,  in  the  form  of  ice  cream.  This  diet,  even  undoubtedly 
after  a  hemorrhage,  may  be  increased,  so  that  the  twenty-four  hours' 
amount  should  contain  900-1,000  calories  (gelatine  with  sugar,  200; 
butter,  235 ;  and  cream,  480-500  calories) .  When  no  further  heraatem- 
esis  follows,  we  can  proceed  rapidly  with  the  increase  in  the  amount 
of  food,  adding  to  this  milk  beaten  eggs,  etc.  The  decoction  of  gela- 
tine, which  becomes  obnoxious  to  certain  patients  on  continued  use,  as 
well  as  produces  constipation,  we  give  in  less  and  less  quantities  until 
within  a  few  days  it  may  be  dropped,  unless  blood  is  again  found  in 
the  vomitus.  There  are  various  ways  in  which  the  gelatine  may  be 
employed,  such  as  calves'  foot  jelly  or  chicken  jelly,  which  can  be 
made  more  palatable  by  the  addition  of  sugar  or  fruit  juice,  or  it  can 
be  added  to  ice-cream.  The  most  convenient  for  use  are  the  varieties 
known  as  Knox's  Crystal  gelatine  and  Plymouth  Rock  gelatine,  which 
can  be  prepared  merely  by  adding  hot  water.     If  patients  object  to 


GASTRIC   ULCER  319 

butter,  we  can  use  as  a  substitute  emulsum  amygdalae,  a  very  palatable 
nutritive,  which  is  equal  to  cream  in  value  and  much  richer  in  nitrog- 
enous elements.  Senator  claims  with  this  method  of  treatment  to 
have  obtained  most  brilliant  results  in  the  treatment  of  gastric  ulcer. 
Summed  up,  we  may  say  that  with  the  Leube  treatment  we  can  always 
obtain  the  very  best  results  with  reference  to  the  healing  of  the 
ulcer,  whether  associated  with  hemorrhage  or  not.  Our  patients, 
however,  will  not  be  in  as  good  condition  as  if  the  Lenhartz  diet  were 
followed.  If  either  treatment  is  properly  carried  out,  our  patients 
should  not  diminish  to  any  extent  in  weight,  and,  if  with  the  former 
method  we  cannot  obtain  this  desirable  result,  we  must  immediately 
adopt  the  latter.  For  the  recurrent  attacks  of  ulcer,  whether  due  to 
the  opening  up  of  an  old  ulcer  partially  healed  or  to  a  new  one,  since 
the  surgeons  tell  us  that  they  often  occur  in  groups — perliaps  not 
synchronous,  but  successive — we  had  best  employ  the  more  liberal  diet 
of  Lenhartz,  especially  with  working  people,  to  whom  a  long  con- 
valescence is  not  permitted  on  account  of  the  necessity  of  quickly  re- 
turning to  their  labors.  As  an  adjuvant  to  the  dietetic  treatment, 
which  is  undoubtedly  of  the  greatest  importance,  we  may  employ 
compresses,  medicinal  agents,  and  mineral  waters.  As  stated,  directly 
after  the  hemorrhage  an  ice  bag  should  be  placed  upon  the  epigas- 
trium, or  a  cold  apparatus  containing  a  coil  of  tubing  may  be  placed 
there,  through  which  water  is  allowed  to  flow  constantly.  If,  after 
three  months,  pain  is  still  present,  it  is  well  for  those  who  can  afford 
it  to  pass  the  night  with  an  electric  pad  attached  to  the  upper  ab- 
domen, which  not  only  alleviates  the  pain,  but  probably  improves  the 
circulation.  A  small  thermophore  pad  may  be  employed,  filled  with 
hot  water  and  replenished  during  the  night.  This,  however,  must  not 
be  employed  for  several  days  after  a  hemorrhage,  for  it  is  not  un- 
usual, after  the  bleeding  has  ceased,  on  application  of  heat  to  the  ab- 
domen to  see  the  hemorrhage  recur. 

Some  authorities  have  employed  gastric  lavage,  with  various  medica- 
ments or  with  ice  water,  for  the  treatment  of  the  ulcer.  Fleiner 
recommends  the  introduction  of  bismuth  in  suspension  by  means  of 
the  stomach  tube.  To  the  rest  of  us,  however,  the  use  of  the  tube 
in  an  ulcer  of  the  stomach  seems  a  very  hazardous  operation  and  one 
to  be  strictly  avoided.  The  increased  blood  pressure  always  associated 
with  gagging  on  the  introduction  of  the  tube,  which  is  strongly  pro- 
vocative of  perforations  of  the  ulcer,  and  fraying  of  the  thrombus, 
which  always  checks  the  bleeding,  would  seem  to  be  absolutely  pro- 
hibitive of  the  introduction  of  the  sound.     From  long  experience  it 


320  DISEASES   OF   THE   DIGESTIVE   TRACT 

has  appeared  to  us  that  it  is  entirely  useless  to  attempt  to  treat  pa- 
tients with  gastric  ulcer  in  an  out-patient  clinic,  and,  though  they 
often  strenuously  object  to  giving  up  their  occupation,  we  always  urge 
strongly  that  they  be  treated  as  indoor  patients.  When  for  economic 
reasons  it  is  impossible  for  the  patient  to  rest  in  bed  and  receive  a 
personally  supervised  diet,  then  it  may  be  sometimes  advisable  to  give 
medicinal  treatment,  though  this  has  never  proved  very  effectual. 
Bismuth  has  been  a  tower  of  strength  in  the  treatment  of  ulcer,  but 
has  almost  as  many  skeptics  as  defenders.  According  to  Fleiner,  10- 
20  grams  of  bismuth  subnitrate  are  to  be  suspended  in  a  glass  of 
water,  and  either  introduced  through  a  stomach  tube  (which  would 
seem  superfluous  and  is  not  without  its  dangers  in  case  of  ulcer)  or 
given  the  patient  to  drink.  After  this  half  an  hour  should  be  passed 
lying  on  the  right  side,  or,  as  Fleiner  remarks,  in  such  position  that 
the  bismuth  comes  in  contact  with  the  ulcer — not  so  easy  a  matter  to 
determine  when  the  position  of  the  ulcer  is  not  known.  After  this 
the  breakfast  may  be  taken.  This  is  to  be  done  daily  for  a  few  days, 
and  then  every  other  day  until  the  symptoms  (pain,  ''occult"  blood, 
etc.)  cease.  It  has  been  demonstrated  on  dogs  that  this  bismuth  forms 
a  layer  over  the  site  of  the  ulcer,  thus  protecting  it  from  the  irritating 
influence  of  food,  gastric  juice,  etc.  The  objections  to  this  mode  of 
treatment  are  that  surgically  it  is  poor  policy  to  induce  a  crust  over  a 
wound,  since  it  diminishes  secretion  and  exaggerates  the  process  of 
necrosis.  Zweig  reports  a  case  where  at  autopsy,  after  death  from 
gastric  ulcer,  the  wound  was  filled  with  a  hard,  firm  crust  of  bismuth, 
separable  with  difficulty  from  the  surface  of  the  former.  It  is  prob- 
able that  bismuth  possesses  largely  anesthetic  properties,  but  does  not 
add  in  any  way  to  the  rapidity  of  the  healing  of  the  ulcer.  Further- 
more, an  occasional  report  of  poisoning  by  these  large  doses  of  the  sub- 
nitrate,  an  effect  largely  overcome  by  the  radiologists  who  employ  the 
subcarbonate,  is  made.  Silver  nitrate  has  won  more  or  less  renown  in 
the  old  days  of  empiricism,  when  we  had  not  the  analysis  of  gastric  con- 
tents to  guide  us,  but  it  has  fallen  into  more  or  less  disrepute.  It  pro- 
duces, if  persisted  in,  a  pronounced  argyria,  and  in  my  experience  a 
physician,  by  taking  it,  became  as  swarthy  as  an  East  Indian.  After- 
ward a  surgeon  removed  his  ulcer,  but,  of  course,  failed  to  remove 
his  argyria.  Then,  too,  it  has  been  demonstrated  that  the  silver  in- 
creases gastric  secretion,  while  at  the  same  time  it  neutralizes  it,  and 
as  it  would  seem,  formed  an  endless  chain,  ever  trying  to  neutralize  the 
hydrochloric  acid  which  it  was  inciting.  Of  course,  from  the  start  its 
use  was  purely  empiric,  based  on  a  reaction  of  a  school  boy 's  test  tube. 


GASTRIC  ULCER  321 

The  dose  when  given  is  0.008-0.03  {Ys-Vi  grain),  and  each  dose  must 
be  given  dissolved  in  at  least  a  tablespoonful  (20  c.c.)  of  water.  The 
olive  oil  treatment,  on  the  contrary,  is  to  be  strongly  recommended,  for 
it  diminishes  secretion  and  forms  a  protecting  surface  over  the  site  of 
the  ulcer.  It  is  to  be  taken  in  tablespoonful  doses  three  times  a  day, 
gradually  increasing  a  tablespoonful  each  day  until  a  cupful  is  ingested 
daily.  The  only  objections  to  its  use  on  the  part  of  the  patient  (con- 
sisting chiefly  of  eructations  of  oil)  may  sometimes  be  overcome  by 
chilling  it,  or  taking  it  in  capsules  or  in  the  form  of  an  emulsion. 
Sometimes,  on  account  of  the  severe  pain,  it  is  necessary  to  prescribe  a 
medicament,  of  which  perhaps  chloroform  is  the  most  valuable.  This 
should  be  given  in  the  following  form : 

'^     Chloroformi 1.0  or  15  minims 

Bismuthi  subcarbonatis     3.0  or  45  grains 

Aquae  destillatse,  q.s.  ad 180.0  or  6  ounces 

M.  Sig. :     One  to  two  tablespoonful s  hourly.     Shake. 

Anesthesin  also,  in  doses  of  0.2  gram  (3  grains),  taken  directly  after 
eating,  has  proved  to  be  very  valuable  in  controlling  the  pain  associ- 
ated with  ulcer.  It  may  be  given  alone  or  added  to  a  bismuth  powder, 
as  follows : 

IJ     Anesthesini 4.0  or  1  dram 

Bismuthi   subcarbonatis    20.0  or  5  drams 

M.     Divide  in  chartulas  XX. 

Sig.:     One  powder  half  an  hour  before  meals  three  times  daily. 

When  the  hypersecretion  is  very  marked,  it  is  sometimes  necessary 
to  neutralize  this  condition  by  means  of  the  ordinary  alkali  powders,  of 
which  the  following  prescription  is  our  favorite : 

5     Eumydrin     0.020  or  l^  grain 

Sodii  citratis. 

Magnesii  oxidi,  aa 20.0       or  %  ounce 

M.     Divide  in  chartulas  XX. 

Sig.:     One  powder  after  eating  three  times  daily. 

Another  form  of  treatment  now  much  in  vogue,  especially  when  the 
ulcer  is  associated  with  hypersecretion  and  spasm  of  the  pylorus,  is  to 
give  twice  daily  a  hypodermic  injection  of  0.0005-0.001  gram  (M20~ 
%o  grain)  of  atropine  sulphate,  which  has  a  marked  sedative  influ- 
ence on  these  conditions,  but  in  many  people  produces  mild  delirium 
or  delirious  fancies,  and  should  not  be  used  unless  the  patient  is  either 
in  a  hospital  or  under  the  direct  observation  of  the  nurse.     For  the 


322  DISEASES   OF   THE   DIGESTIVE    TRACT 

purpose  of  convenience,  we  may  use  the  hypodermic  tablets  put  up  by 
the  majority  of  manufacturing  pharmacists,  suitably  divided  into  doses 
of  Mso  to  Yioo  grain.  This  atropine  is  especially  recommended  where 
gastric  ulcer  is  associated  with  vagotonus,  whose  relation  to  enter- 
optosis  will  be  discussed  more  fully  later.  While  many  reports  of  hal- 
lucinations from  the  employment  of  atropine  have  been  published, 
Zweig  claims  that  he  has  never  seen  any  ill  results  from  the  continu- 
ance of  this  treatment. 

The  employment  of  Carlsbad  water  in  ulcer  of  the  stomach  has  no 
purpose  except  where  the  acidity  of  the  gastric  contents  reaches  a  high 
point,  when  the  use  of  the  water  or  a  teaspoonful  of  the  artificial 
Carlsbad  dissolved  in  a  cup  of  hot  water,  taken  on  rising  and  another 
before  going  to  bed,  will  reduce  the  acidity,  according  to  Jaworski,  in 
the  shortest  time,  though  other  observers  are  still  skeptical  in  regard 
to  this.  This  treatment,  however,  should  follow  the  rest-diet  period, 
for  nothing  could  be  more  unwise  than  to  give  Carlsbad  directly  after 
a  hemorrhage  or  in  the  acute  stage  of  the  illness.  Furthermore,  the 
constipation  which  often  persists  with  ulcer  is  relieved,  and  to  this, 
perhaps,  is  due  the  reduction  of  the  secretion,  since  it  has  often  ap- 
peared to  us  that  confined  bowels  induce  hypersecretion.  Naturally, 
where  the  patient  can  afford  it,  a  visit  to  Carlsbad  and  a  systematic 
drinking  of  the  water  is  of  advantage,  but  this  should  never  be  advised 
until  all  acute  symptoms  of  the  disease  have  passed  away.  This  treat- 
ment should  be  continued  for  three  months  after  the  acute  attack,  and 
unquestionably  is  a  good  prophylactic  against  a  recurrence.  Levico 
water  has  also  served  us  well  to  overcome  the  anemia  following  ulcer. 
It  is  well  to  begin  with  a  small  dose  (a  tablespoonful)  and  gradually 
increase  to  the  limits  of  toleration,  watching  results  for  the  beginning 
of  toxic  arsenical  symptoms,  coryza,  or  nausea. 

Now  the  question  arises,  when  are  we  to  regard  the  ulcer  as  healed? 
We  have  no  criterion  to  settle  this  important  question,  but,  if  the  spon- 
taneous pain  ceases  and  there  is  no  tenderness  on  pressure,  and.  as 
Boas  insists,  chemical  blood  is  absent  from  the  stool,  we  may  consider 
that  scar  tissue  has  formed  over  the  ulcer.  Even  when  the  pain 
ceases,  if  careful  examination  of  the  feces  still  shows  blood,  the  patient 
must  continue  all  the  precautions  as  to  food  and  exercise  as  before. 
Hence  the  blood  in  the  stool  wins  the  greatest  significance,  for  the  ulcer 
may  be  healed  and  the  adhesions  produced  cause  pain  and  tenderness 
on  pressure,  but,  as  long  as  the  slightest  trace  of  blood  is  found  in  the 
stool  on  a  meat-free  diet,  we  are  assured  that  the  process  of  healing  is 
not  complete.     When  the  ulcer  assumes  this  indolent  character  and 


GASTRIC   ULCER  323 

there  is  evidence  that  the  process  is  still  active,  it  may  be  necessary  to 
repeat  the  rest-diet  cure  several  times  before  repeated  examination  of 
the  stool  assures  us  that  complete  cicatrization  has  taken  place.  These 
are  the  cases  which  haunt  our  clinics,  obtaining  a  little  temporary  re- 
lief, but  never  complete  restoration  to  health  until  a  gastroenterostomy 
is  performed.  The  latest  statistics  with  reference  to  a  cure  by  internal 
treatment  show  that  77  per  cent  are  relieved  by  this  means,  23  per  cent 
are  not  aided,  and  7-10  per  cent  die.  Lenhartz  and  Leube  both  give  a 
much  greater  percentage  of  cures  by  these  means,  but  ulcer  is  notorious 
as  recurring,  and,  when  a  physician  discharges  a  patient  as  cured  be- 
cause symptoms  have  ceased,  he  often  loses  sight  of  him,  and  later  an- 
other physician  or  hospital  puts  him  through  the  same  course  of  treat- 
ment with  the  same  result.  Again,  if  one  can  rely  on  the  surgeon, 
multiple  ulcers  are  common,  judging  from  the  scars  found  at  operation, 
and  what  are  regarded  as  recurrences  of  the  same  ulcer  may  be  new 
ulcers  dependent  on  the  condition  of  the  patient — whatever  it  may  be 
which  produces  them — so  that  we  should  not  treat  the  ulcer,  but  the 
dyscrasia,  and  that  still  remains  the  sphinx  of  pathology.  Syphilis  of 
the  stomach,  described  by  Einhorn  and  others,  is  a  rare  disease,  seldom 
diagnosed,  and  not  particularly  amenable  to  treatment.  It  is  usually 
hereditary,  and  consists  of  infiltrations,  ulcers,  or  formation  of  scar 
tissue.  Similar  changes  may  also  occur  in  the  intestine,  and  the  simul- 
taneous discovery  of  sj'philitic  processes  in  the  liver  assures  the  diag- 
nosis. Sometimes  the  cure  of  a  long-continued  gastric  ulcer  by  anti- 
syphilitic  treatment  is  reported,  but  it  has  also  seemed  to  us  from  a 
very  close  sequence  that  ulcer  has  been  produced  by  repeated  salvarsan 
injections.  Tubercular  ulcer  of  the  stomach  is  a  very  rare  occurrence 
as  compared  with  that  of  the  intestine.  Eisenhardt  reports  that  in 
five  hundred  and  sixty-seven  instances  of  tubercular  ulcer  of  the  in- 
testine he  could  find  only  one  of  the  stomach,  and  only  forty  cases  could 
be  found  in  medical  literature.  The  ulcerations  are  distinguished  by 
much  thickened  borders  and  pale  base,  in  which  base  tubercular  and 
giant  cells  are  numerous.  Smaller  caseous  infiltrations  have  also  been 
found  in  the  submueosa  of  the  stomach,  containing  tubercle  bacilli. 
Simonds  in  two  thousand  autopsies  of  tubercular  patients  found  sec- 
ondary ulcer  of  the  stomach  only  forty  times.  The  operative  treatment 
which  is  employed  for  excessive  hemorrhage,  perforation  in  the  peri- 
toneal cavity,  with  its  chances  for  success,  has  been  discussed  fully  in 
Chapter  VIII  and  repetition  is  unnecessary.  The  treatment  of  stenosis 
and  adhesions  will  fall  naturally  into  the  next  chapter,  and  will  not 
be  anticipated  here. 


CHAPTER  XI 

ECTASIA  VENTRICULI  (DILATATION  OF  THE 
STOMACH) 

Disturbances  of  motility  form  one  of  the  most  important  features  of 
gastric  disorders,  perhaps  more  so  than  than  those  of  secretion,  because 
it  is  beginning  to  be  a  well-accepted  axiom  that  the  latter  often  de- 
pend on  the  former.  Still,  there  is  much  argument  and  discussion  over 
the  significance  of  impaired  motility  per  se  and  true  dilatation.  We 
cannot  begin  to  give  in  full  the  mass  of  material  which  has  accumu- 
lated in  regard  to  this  question,  but  wall  consider  only  such  points  as 
are  particularly  associated  with  its  therapy.  When  an  attempt  is 
made  to  give  a  definition  of  ectasis,  we  immediately  come  on  the  rela- 
tive importance  of  anatomical  changes  and  the  functional  ability  of 
the  stomach  to  empty  itself  in  a  prescribed  time — as  one  physician  ex- 
presses himself,  ' '  The  radiogram  of  any  portion  of  the  tract,  no  matter 
how  distorted  or  bizarre  it  may  appear,  means  nothing  to  me  until  I 
learn  what  that  portion,  be  it  stomach  or  colon,  can  do" — so  that,  in 
order  to  make  a  dia^osis  of  dilated  stomach,  we  must  not  only  deter- 
mine the  size  of  its  percussion  outline,  whether  increased  above  the 
normal  or  not,  but  we  must  also  by  means  mentioned  learn  how  long 
it  takes  that  organ  to  empty  itself  of  an  ordinary  meal.  This  pre- 
caution is  based  on  the  fact  that  we  can  often  demonstrate  a  much  en- 
larged stomach  whose  functions  are  perfectly  performed  and  whose 
possessor  never  has  an  untoward  symptom  relating  to  his  digestion. 
This  latter  condition  is  sometimes  called  megalogastria,  may  be  eon- 
genital  or  acquired  (frequent  pregnancies),  and  is  almost  invariably 
associated  with  gastroptosis.  In  this  case  we  can  readily  see  the  pro- 
trusion of  the  abdomen  formed  by  the  enlarged  and  sunken  stomach, 
its  excursion  on  deep  respiration,  and  still  the  patient  makes  no  com- 
plaint of  disturbed  digestion.  Such  a  stomach  could  not  by  any 
stretching  of  the  imagination  be  regarded  as  pathologic,  so  that  our 
definition  of  ectasis  (dilated  stomach)  must  be  an  enlarged  stomach, 
with  unimpeachable  evidence  of  impaired  motility,  as  evinced  by  tardy 
emptying.  Furthermore,  we  must  consider  how  great  the  impairment 
of  motility  must  be  to  regard  the  case  as  in  the  category  of  dilated 

324 


ECTASIA   VENTRICULI    (DILATATION   OF   THE   STOMACH)  325 

stomachs.  To  do  this,  it  is  advisable  to  divide  the  condition  into  two 
classes:  (1)  first  degree,  where  the  emptying  is  delayed,  but  finally  ac- 
complished— a  state  sometimes  called  atony,  or,  better,  hypotony ;  and 
(2)  second  degree,  where  the  stomach  is  never  fully  emptied,  but,  even 
fasting,  contains  some  food  residue.  This  is  true  ectasia  ventriculi. 
If  these  were  progressive  divisions  of  the  same  pathologic  condition, 
then  the  former  would  imperceptibly  advance  into  the  latter  grade, 
but  such  is  not  the  fact,  and  they  both  remain  as  distinct  entities.  The 
hypotony  is  dependent  on  the  weakness  of  the  muscles  of  the  stomach, 
may  be  congenital  or  acquired,  and  usually  chronic,  but  may  rarely 
be  acute,  as  mentioned.  This  condition  is  ordinarily  only  a  symptom 
of  a  state  of  general  muscular  weakness,  called  by  Stiller  ' '  myasthenia 
universalis  congenita."  Just  as  we  may  have  individuals  whose  arm 
muscles  remain  weak,  undeveloped,  and  unable  to  raise  a  burden  com- 
mensurate with  the  sex  and  age  of  the  possessor,  so  we  may  have  gastric 
muscles  which  are  unable  to  contract  firmly  on  the  mass  in  the  stomach 
and  force  it  into  the  duodenum.  In  such  cases  there  are  other  signs 
of  the  habitus  enteropticus,  and  no  therapeutic  measure  has  any  in- 
fluence on  the  stomach  which  does  not  at  the  same  time  tend  to  build 
up  the  whole  muscular  structure  of  the  individual,  as  well  as  improve 
his  general  condition.  This  is  often  best  accomplished  by  increasing 
in  every  way  the  patient's  nutrition,  for  he  is  as  a  rule  markedly 
undernourished.  Vastly  different  from  this  is  the  true  dilated 
stomach,  which  depends  on  disease  per  se  of  the  organ,  consisting 
usually  of  a  hindrance  to  the  departure  of  the  food  from  the  stomach, 
and  has  nothing  to  do  with  the  general  condition  of  the  patient.  The 
stomach  struggles  harder  and  harder  to  force  the  food  through  the 
narrowed  pylorus,  often  becoming  hypertrophied  in  the  process  until, 
like  decompensation  of  a  hypertrophied  heart,  the  muscles  finally  yield 
to  superior  force,  and  we  begin  to  find  gastric  insufficiency,  dilatation, 
and  stasis.  As  long  as  hypertrophy  of  the  gastric  muscles  persists,  the 
stomach  is  able  for  a  long  period  to  force  its  contents  through  the 
orifice  into  the  duodenum.  In  other  words,  referring  to  the  illustra- 
tion of  the  heart,  compensation  is  nearly  perfect,  and  only  relative  in- 
sufficiency exists,  but,  unless  relief  is  given  by  making  a  new  communi- 
cation between  the  stomach  and  the  intestine  (''window  in  the 
stomach,"  as  the  newspapers  have  popularized  it),  this  relative  insuf- 
ficiency is  converted  into  an  absolute  incompetency,  and  more  food  is 
ejected  by  vomiting  than  reaches  the  intestine.  But,  apart  from  this, 
we  may  have  disease  of  the  muscular  structure  of  the  stomach  itself — 
either  atrophy,  amyloid  degeneration,  or  cancerous  infiltration.     In 


326  DISEASES   OF   THE   DIGESTIVE   TRACT 

this  case  there  is  no  anticipatory  hypertrophy,  but  the  ejective  power 
of  the  organ  is  impaired,  insufficiency  and  enlargement  take  place,  and 
the  result  is  the  same  as  in  the  former  instance — stasis — which  may  be 
regarded  of  primary  origin  instead  of  secondary.  Very  rarely  we 
may  have  a  paralysis  of  the  muscles  of  the  stomach  from  central  origin, 
as  in  acute  dilatation  following  operation, '  or  severe  shock,  and  this 
condition  is  usually  fatal.  Occasionally  we  have  a  temporary  acute 
dilatation  of  the  stomach  brought  on  by  excessive  eating,  aided  largely 
by  alcohol,  as  is  seen  in  the  copious  amounts  of  partially  digested  food 
brought  up  by  one  several  hours  after  a  debauch,  particularly  when 
the  interval  has  been  passed  in  a  drunken  stupor.  In  this  chapter  only 
the  true  gastric  dilatation  will  be  considered,  as  hypotony  belongs 
rather  to  the  functional  forms  of  gastric  disorders. 

Causes. — The  causes  of  this  disease  are,  first,  narrowing  of  the 
pylorus,  and,  second,  disease  of  the  musculature  of  the  stomach.  The 
stenosis  of  the  pylorus  may  be  congenital  or  acquired.  The  former 
usually  leads  rapidly  to  the  death  of  the  infant,  if  not  operated,  from 
constant  vomiting  and  inanition.  The  acquired  form  may  arise  from 
pressure  on  the  pylorus  from  outside,  disease  of  the  orifice  itself,  or 
pressure  from  the  inside.  The  most  common  cause  of  external  pres- 
sure is  adhesions,  producing  twists,  elongation,  or  compression,  and 
arising  from  the  adjacent  organs  (gallbladder,  pancreas,  mesentery,  or 
intestine),  or  by  tumors  causing  compression  (large  gallstones).  In- 
ternally the  pylorus  may  be  narrowed  by  scar  tissue  from  old  ulcers, 
by  pyloric  spasm  due  to  fissures,  from  the  caustic  effects  of  acids  and 
alkalies  (drinking  lye),  from  thickening  of  the  mucous  membrane,  by 
a  gastritis  largely  confined  to  the  pylorus,  and  by  tumors  (carcinoma, 
polypi,  etc.)  Another  cause  much  more  common  than  is  generally 
supposed,  as  it  seems  to  us,  is  severe  gastroptosis,  which  may  not  only 
cause  obstruction  of  the  pylorus  by  a  kink,  but  may  also  cause  narrow- 
ing of  the  choledochus  with  jaundice. 

Symptoms. — The  symptoms  will  vary  according  to  the  antecedent 
illness,  and  will  differ  markedly  according  to  whether  the  dilatation 
is  caused  by  malignant  disease  or  arises  from  pyloric  spasm.  Hence 
we  can  describe  only  the  symptoms  produced  by  the  ectasia  itself. 
Subjectively,  symptoms  may  be  wanting  just  as  long  as  the  hyper- 
trophied  gastric  muscles  are  able  to  drive  the  food  through  the  nar- 
rowed pylorus,  but  will  begin  as  soon  as  this  power  commences  to  flag. 
These  consist  of  pressure  and  tension  after  every  large  meal,  but  there 
may  be  no  actual  pain,  though  an  ignorant  patient  often  describes  the 
sensation  as  pain.     Soon,  however,  the  sense  of  tension  persists  after 


ECTASIA   VENTRICULI    (DILATATION   OP    THE   STOMACH)  327 

smaller  meals  and  often  fails  to  relax  in  the  interval  between  the  meals, 
so  that  he  describes  it  as  continuous,  relieved  only  by  sleep.  He  notes 
also  that  the  epigastrium  is  visibly  protruded,  in  which  ease  straps  on 
a  man  and  corsets  on  a  woman  cannot  be  endured.  Soon  come  eructa- 
tions, which  first  taste  of  the  food  swallowed,  then  sour  or  bitter,  and 
finally  with  an  odor  of  putrefaction  (HjS).  One  instance  comes  to 
our  mind  where  the  patient's  involuntarily  eructation  in  the  office 
necessitated  open  windows  for  several  minutes  to  dispel  the  nauseating 
odor.  Soon  the  patient  experiences  the  powerful  peristaltic  actions  of 
the  stomach,  which  may  not  at  first  be  painful,  but  are  often  accom- 
panied by  a  gush  of  the  gastric  contents  into  the  mouth.  These  must 
not  be  confounded  with  the  pulsations  of  the  aorta,  experienced  by 
many  patients  who  suffer  from  gastroptosis.  Thirst  is  a  common  symp- 
tom, which  even  large  draughts  of  water  fail  to  quench.  As  absorption 
is  largely  the  function  of  the  intestine  and  fluid  cannot  escape  from 
the  stomach,  the  skin  becomes  dry  and  wrinkled,  while  rapid  desquama- 
tion of  the  superficial  layer  may  take  place.  The  most  common  symp- 
tom, however,  is  vomiting,  which  is  unlike  the  ordinary  vomiting  of 
gastric  catarrh  that  follows  very  shortly  after  food  is  taken.  Here 
the  vomiting  is  more  periodic,  occurring  at  intervals  of  a  day  or  so, 
when  large  quantities  of  sour-smelling  gastric  contents  are  evacuated, 
often  containing  portions  of  food  taken  two  to  four  days  before.  The 
vomiting  occurs  oftener  and  is  more  copious,  and  the  patient  becomes 
rapidly  emaciated;  headache  and  nausea  are  fairly  constant  and  con- 
tinuous, while  numbness  of  the  fingers  and  toes,  obstinate  constipation, 
and  diminution  of  urine  exist.  Very  rarely  tetany  may  arise,  a  most 
fatal  complication.  ^Milder  degrees  of  twitching  of  certain  groups  of 
muscles  and  even  mild  epileptoid  attacks  have  also  come  to  our  atten- 
tion, unquestionably  dependent  on  the  dilatation  of  the  stomach,  since 
relief  of  this  condition  caused  the  attacks  to  cease.  Objectively,  the 
marked  emaciation  and  dryness  of  the  skin,  with  the  pinched  look,  at- 
tract attention,  though  these  may  be  lacking  in  the  early  stage  of  the 
disease.  Through  the  thinned  and  fat  free  abdominal  walls  during  a 
peristaltic  contraction  one  can  see  the  contour  of  the  stomach  rise 
from  the  surface,  by  which  both  larger  and  lesser  curvature  can  be 
easily  made  out.  During  the  intervals  of  rest  the  borders  of  the 
stomach  are  discernible  with  a  good  light,  but  so  are  they  in  marked 
gastroptosis  in  women  with  lax  abdominal  walls.  Later  on  in  the 
progress  of  the  disease  waves  can  be  seen  running  from  the  patient's 
left  to  the  right,  which  often  culminate  in  a  continued,  almost  tetanic, 
contraction  of  the  stomach  (rigidity).    One  should  not,  however,  lose 


328  DISEASES   OF   THE   DIGESTIVE   TRACT 

sight  of  the  fact  that  a  pyloric  stenosis  and  dilated  stomach  may  exist 
without  these  signs  of  an  exaggerated  gastric  peristalsis  when  the  stage 
of  decompensation  has  arrived.  Two  of  our  patients  have  been  oper- 
ated for  a  chronic  ulcer  and  marked  stenosis  found  when  no  gastric 
rigidity  ever  occurred  under  the  most  careful  observation.  When 
these  stomachs  are  inflated  with  air  or  carbon  dioxide,  it  can  be  readily 
seen  that  their  dimensions  far  exceed  those  normally  found.  Palpation 
also  will  afford  evidence  of  dilatation,  for  succussion  exists  far  below 
the  navel  and  seven  to  eight  hours  after  food  is  taken.  The  best 
means,  however,  of  diagnosis  is  the  test  meal  of  Riegel,  or  rather  an 
adaptation  of  it,  consisting  of  meat  and  potato,  bread  and  butter,  and 
boiled  rice  with  raisins,  or,  better,  rice  pudding  with  raisins.  If  the 
patient  is  washed  out  seven  hours  after,  and  food  fragments  to  any 
extent  are  found,  gastric  insufficiency  is  present,  and  with  the  physical 
signs  of  increased  gastric  area  our  diagnosis  is  assured.  As  there  may 
be  several  degrees  of  insufficiency,  if  after  the  first  removal  in  seven 
hours  much  debris  is  found,  particularly  if  food  from  a  previous  day 
is  found,  a  second  removal  after  the  same  meal  taken  at  evening  should 
occur  the  next  day.  In  fact,  in  our  out-patient  clinics  this  washout  in 
the  morning  after  the  evening  Riegel  meal  is  the  routine,  and  the  seven 
hours  between  is  usually  chosen  only  for  special  cases;  even  in  the 
latter  case,  where  much  insufficiency  exists,  copious  food  fragments 
will  be  found,  and  the  gastric  contents  withdrawn  after  the  subse- 
quent test  breakfast  will  be  found  to  be  much  increased.  The  x-ray  ex- 
amination also  aids  very  materially  in  that  a  twenty-four  hour  bis- 
muth remnant  speaks  emphatically  for  pyloric  narrowing. 

The  ectasia  produced  by  intermittent  spasmodic  contraction  of  the 
pylorus  can  also  be  easily  diagnosed.  Such  attacks  often  come  on  dur- 
ing the  night,  and  a  morning  lavage  following  will  either  show  food 
remnants,  often  with  sarcinffi,  or  a  considerable  amount  of  almost  pure 
gastric  juice.  These  eases  are  often  the  most  satisfactory  for  treat- 
ment, because  a  mild  diet  and  the  use  of  antispasmodics  will  so 
ameliorate  the  condition  that  often  a  subsequent  lavage  after  an  in- 
terval of  two  weeks  will  show  neither  food  fragments,  gastric  juice, 
nor  sarcinse.  Where  such  a  favorable  outcome  does  not  follow,  one  can 
be  well  assured  that  an  organic  lesion  is  the  cause,  a  chronic  pyloro- 
duodenal  ulcer  being  the  most  common.  When  the  dilatation  is  caused 
by  obstruction  from  a  pyloro-gastritis  (linitis  plastica),  we  always  have 
a  long  antecedent  history  of  gastritis,  with  loss  of  hydrochloric  acid, 
and  an  abundance  of  mucus  in  the  contents.  In  the  course  of  the  dis- 
ease a  marked  dilatation  of  the  stomach  occurs,  which  taken  with  the 


ECTASIA   VENTRICULI    (DILATATION   OF    THE   STOMACH)  329 

emaciation,  loss  of  hydrochloric  acid  and  presence  of  lactic  acid  leads 
one  to  think  of  cancer,  but  in  my  experience  the  patient  never  ex- 
hibits the  peculiar  cachectic  color  with  this  disease  that  he  does  with 
cancer  and,  of  course,  the  duration  of  the  former  is  much  longer. 

Treatment. — The  treatment  must  be  preceded  by  the  most  exacting 
study  to  establish  whether  we  are  dealing  wdth  a  hypotony,  associated 
with  general  muscular  weakness,  or  a  real  stenosis.  The  former  de- 
mands the  most  vigorous  roborant  regimen — cold  baths,  increased 
nutrition,  massage,  well-selected  moderate  exercise,  and  change  of 
climate,  the  mountains  proving  most  satisfactory;  the  latter  requires 
that  the  stomach  be  spared  as  much  as  is  consistent  with  the  establish- 
ment of  normal  nutrition  to  overcome  the  marked  emaciation.  An 
equally  grave  error  is  committed  whether  we  adopt  forced  feeding  in 
ectasia  or  a  dry  diet  in  hypotony.  Unfortunately,  both  these  errors 
are  committed  by  physicians,  largely  because  sufficient  care  is  not  taken 
in  establishing  a  correct  diagnosis.  Every  "slopping"  stomach  does 
not  spell  dilatation,  nor  is  a  morning  residue  to  be  interpreted  as  ex- 
aggerated myasthenia  gastrica. 

The  treatment  of  true  ectasia  is  made  up  of  (1)  dietetic,  (2)  phys- 
ical, and  (3)  medicinal  agencies: 

1.  The  diet  must  be  based  on  the  degree  of  insufficiency  and  the 
character  of  the  secretion.  The  food  should  always  be  in  such  a  form 
as  demands  the  least  effort  on  the  part  of  the  weakened  gastric  mus- 
culature to  drive  it  through  the  narrowed  or  normal  pylorus.  Our 
advice  often  is  that  food  must  be  so  fully  divided  that  it  will  pass 
through  a  colander.  The  amount  taken  at  one  time  must  be  minimal, 
and,  in  order  to  maintain  a  nutritive  equilibrium,  the  meals  must  be 
taken  at  short  intervals.  The  quality  of  the  food  must  depend  largely 
on  the  character  of  the  secretion.  If  hydrochloric  acid  is  abundant, 
we  may  make  free  use  of  protein  in  the  form  of  meat,  fish,  fowl,  eggs, 
cheese,  and  milk;  meat  may  be  given  in  finely  divided  form,  for  the 
proteolytic  activity  of  the  digestive  fluid  is  unimpaired.  Carbohy- 
drates are  less  desirable,  because  the  increased  natural  acid  inhibits 
amylolysis.  Vegetables  must  be  given  in  puree  form  and  in  small  por- 
tions, and  bread  is  best  employed  as  toast  and  zwieback.  Sugar  is  to 
he  taken  sparingly,  since  it  incites  a  marked  transudation  (diluting 
fluid)  into  the  stomach's  interior.  Fats  are  usually  badly  borne,  and 
resulting  fatty  acids  arising  from  the  stasis  act  as  an  irritant.  Un- 
salted  butter  and  cream,  as  well  as  good  olive  oil,  can  be  employed  in 
moderation.  All  condiments,  alcohol,  and  excessive  use  of  tobacco 
must  be   avoided.     When,   from   the   overstimulation   of  the   peptic 


330  DISEASES   OF   THE   DIGESTIVE   TRACT 

glands  by  the  long  delay  of  the  food  in  the  stomach,  they  fail  in 
their  secretion,  the  character  of  the  diet  must  change;  protein  must 
be  reduced  and  limited  to  the  most  digestible — white  meat  of 
chicken,  oysters,  soft  cream  cheese,  dropped  eggs,  and  minced  fish. 
Here  is  where  the  predigested  protein  foods — laibose,  somatose,  etc. — 
as  adjuvants  come  into  their  own.  The  feature  to  be  especially  empha- 
sized in  the  diet  is  that  the  food  shall  be  in  a  semisolid  form.  The  em- 
ployment of  a  dry  diet,  as  was  formerly  the  custom  in  both  hypotony 
and  ectasia,  has  no  purpose  whatever,  but  it  has  been  shown  experi- 
mentally that  first  the  fiuid,  then  the  semisolid,  and  last  thg  solid 
articles  of  food,  after  being  liquefied  by  the  transudation,  sometimes 
called  the  diluting  fluid,  enter  the  duodenum  through  the  orifice. 
Hence  it  can  be  seen  that  the  stomach  provides  fluid  for  liquefying 
solid  articles  of  food  from  its  own  circulatory  vessels,  and  Kemp  has 
shown  that  after  the  dry  test  breakfast  the  amount  of  gastric  contents 
withdrawn  is  often  greater  than  when  fluid  is  given,  since  it  probably 
furnishes  a  greater  incentive  to  the  secreting  powers  of  the  stomach. 
Thus  solid  food  alone  may  cause  a  greater  volume  from  which  the  organ 
is  to  free  itself  than  when  liquid  or  semisolid  articles  are  taken.  Our 
greatest  precaution,  then,  must  be  that  liquid  food  shall  contain  the 
largest  possible  nutritive  value,  which  can  be  accomplished  by  using 
milk  as  a  basis  and  adding  the  various  flours,  rice,  predigested  foods^ 
etc.  The  amount  of  fluid  taken  must  not  exceed  1,000-1,500  c.c.  (2  to 
3  pints),  and,  whenever  possible,  should  be  made  nutritious  by  the 
addition  of  egg  albumin,  sugar,  malted  milk,  oatmeal,  etc.,  to  the 
water,  or  the  use  of  the  milkshake.  All  effervescent  drinks  are  to  be 
avoided,  but  iced  coffee,  tea,  etc.,  well  fortified  with  cream,  may  be 
used,  or,  if  the  thirst  is  excessive,  the  mouth  may  be  rinsed  out  with  ice 
water,  which  is  not  to  be  swallowed.  When,  however,  the  motor  power 
of  the  stomach  reaches  its  lowest  ebb  and  the  organism  suffers  from  its 
lack  of  fluid  (dry  and  wrinkled  skin),  rectal  injections  of  salt  water 
(Yo  teaspoonful  to  a  pint)  may  be  employed  several  times  daily,  and  it 
is  sometimes  surprising  to  note  the  rapidity  with  which  such  injec- 
tions are  absorbed.  Patients  will  feel  discomfort  from  the  retention 
of  a  cupful  at  first,  but  will  soon  be  taking  a  pint  at  a  time  Avithout  any 
difficulty.  Instead  of  the  salt  a  teaspoonful  of  beef  extract  may  be 
stirred  into  the  water  before  injection.  The  best  indication  for  the 
use  of  these  enemata  is  the  diminution  of  the  urine ;  when  this  falls  to  a 
pint  daily,  enemata  must  be  begun  immediately.  AYhen,  in  spite  of 
diet  and  daily  lavage,  the  vomiting  persists  and  the  weight  sinks,  it  is 
advisable  to  put  the  patient  to  bed  and  give  nourishment  wholly  by 


ECTASIA   VENTRICULI    (DILATATION   OF    THE   STOMACH)  331 

rectum  for  ten  days,  when  very  often  the  sufferer  can  begin  to  take 
food  again  per  os  without  discomfort,  a  result,  unfortunately,  which  is 
not  permanent.  These  views  are  summarized  in  the  following  diet 
list: 

DIET   LIST   IN    DILATATION    OP    THE    STOMACH    WITH    ABSENCE    OF    HYDRO- 
CHLORIC   ACID. 

On  rising. — Gastric  lavage. 

Breakfast. — A  large  cup  or  bowl  of  hot  milk,  with  a  tablespoonful  of 
tea  or  coffee  in  it,  and  two  slices  of  toast  well  buttered. 

Midforenoon. — A  bowl  of  oatmeal  gruel  made  with  milk,  with  a 
tablespoonful  of  gliadine  or  laibose  cooked  in  it,  or,  if  preferred,  it 
may  be  eaten  as  porridge  with  milk  and  sugar. 

Dinner. — Potato  or  pea  soup  (cooked  until  creamy,  no  lumps),  with 
a  beaten  egg  cooked  in  it ;  three  tablespoonfuls  of  lean  minced  chicken, 
beef,  or  fish  (no  mackerel,  halibut,  or  salmon),  best  put  through  a  meat 
cutter  before  cooking ;  two  slices  of  toast  buttered,  as  before,  and  three 
tablespoonfuls  of  mashed  potato  or  squash. 

Midafternoon. — A  large  cup  of  milk,  with  a  teaspoonful  of  cocoa, 
and  two  zwiebacks  (zwieback  to  be  moistened  in  the  milk  before  eaten). 

Supper. — A  bowl  of  oatmeal,  tapioca,  or  cornmeal  gruel  and  two 
slices  of  toast  well  buttered,  as  before.  If  patients  awaken  during  the 
night,  they  may  be  given  a  cup  of  custard  or  some  gelatine  with  milk 
and  sugar,  flavored  with  some  fruit  (Knox's  or  Crystal  Rock). 

As  stated,  when  there  is  an  excess  of  hydrochloric  acid,  we  adopt  a 
diet  containing  much  more  protein,  whose  general  characteristics  are 
given  in  this  dietary : 

DIET   LIST    IN    DILATATION    OF    THE    STOMACH    WITH    EXCESSIVE    HYDRO- 
CHLORIC  ACID. 

On  rising. — Gastric  lavage. 

Breakfast. — Two  dropped  eggs  on  toast,  cup  of  cocoa  made  with 
milk,  to  which  a  tablespoonful  of  cream  is  to  be  added. 

11  a.  m. — An  eggnog,  with  a  teaspoonful  of  laibose  added. 

Dinner. — Chopped  or  minced  chicken,  fish,  or  tenderloin,  cooked 
with  butter;  three  tablespoonfuls  of  mashed  potato,  squash,  or  white 
turnip,  or  well-boiled  rice;  a  light  pudding  (Indian  meal,  bread,  or 
gelatine),  with  cream  and  sugar;  a  glass  of  milk,  with  a  tablespoonful 
of  laibose  or  somatose. 

4  p.  yn. — A  bowl  of  custard,  with  two  slices  of  zwieback  well  buttered. 

Supper. — Tenderloin  steak  or  a  chop  well  minced  with  knife  and 


"332  DISEASES   OF   THE   DIGESTIVE   TRACT 

fork ;  two  slices  of  toast,  with  a  ball  of  butter  and  cream  cheese  spread 
•over  them ;  a  cup  of  cocoa  made  as  before. 

Bedtime. — A  glass  of  milk,  with  a  tablespoonful  of  laibose. 

2.  Physical  treatment  consists  almost  wholly  of  lavage,  and  here 
again  a  marked  distinction  must  be  made  between  the  hypotony,  which 
is  harmed  instead  of  benefited  by  this  treatment,  and  true  dilatation 
due  to  stenosis.  Where  washing  out  the  stomach  removes  the  stag- 
nating mass  made  up  of  the  previous  day's  food,  patients  (those  who 
perform  it  themselves  as  regularly  as  they  brush  their  teeth  or  make 
their  toilet  mornings)  assure  us  that  it  is  an  absolute  prerequisite  for 
the  enjoyment  of  their  breakfast.  Furthermore,  this  procedure  gives 
the  stomach  a  short  period  of  rest  from  its  burden,  and  checks  the 
hypersecretion  which  is  brought  about  by  the  irritation  of  the  con- 
stant presence  of  food.  When  this  act  should  be  performed  depends 
largely  on  the  severity  of  the  case.  If  the  retention  is  only  moderate 
and  motility  delayed,  but  not  to  the  point  where  much  residue  is  found 
in  the  stomach  mornings,  the  evening  is  the  best  time,  for  then  the 
organ  gains  a  long  period  of  rest.  When,  on  the  contrary,  a  large 
food  residue  is  found  mornings  after  the  Riegel  meal  of  the  evening 
before,  then  morning  is  the  time,  for  we  must  give  every  opportunity 
for  the  food  to  pass  into  the  duodenum  in  order  to  overcome  the  pro- 
gressive emaciation.  In  the  former  case  the  last  meal  must  be  taken 
not  later  than  6  p.  m.  and  the  lavage  take  place  not  earlier  than  10 
p.  M. 

The  advantage  of  systematic  lavage  is  soon  seen.  The  vomiting 
«eases,  there  is  less  pain,  eructations  diminish,  the  urine  increases  in 
amount,  and  the  patient  soon  begins  to  take  on  weight.  Furthermore, 
we  have  evidence  of  improvement  in  the  fact  that  the  mass  of  food  frag- 
ments washed  out  mornings  grows  less  and  less  until  we  obtain  only  a 
large  amount  of  gastric  juice,  which  lends  to  the  wash  water  a  marked 
hydrochloric  acid  reaction  when  Toepfer's  reagent  is  added.  In  other 
words,  the  ectasia  ceases,  but  the  hypersecretion  persists.  How  long 
this  lavage  should  be  continued  is  difiicult  to  say.  Patients  have  come 
under  our  observation  who  have  continued  it  for  years,  feeling  per- 
fectly well  in  the  meantime,  until,  wearied  of  its  annoyance,  they  have 
elected  an  operation.  Others  after  a  short  period  are  temporarily 
relieved  of  its  employment  until  some  indiscretion  in  diet  or  an  ex- 
cessive meal,  as  at  a  banquet,  has  demanded  its  renewal  and  the  stasis 
lias  appeared  intermittently.  When  the  dilatation  is  dependent  on 
malignant  disease,  but  little  can,  of  course,  be  expected  of  the  daily 
washing;  in  fact,  the  patient  seems  to  become  worse  from  the  ex- 


ECTASIA   VENTRICULI    (DILATATION   OF   THE   STOMACH)  333 

haustion  produced  by  it.  The  most  brilliant  results  are  found  where 
the  stenosis  is  due  to  the  formation  of  sear  tissue  following  an  ulcer  or 
pyloric  spasm  caused  by  an  erosion  or  fissure. 

As  far  as  our  experience  is  concerned,  but  little  is  gained  by  the- 
addition  of  medicinal  agents  to  the  water  used  for  washing,  except 
where  marked  hypersecretion  or  putrefaction  exists ;  in  the  former  case 
sodium  carbonate  or  artificial  Carlsbad  salts  (a  half  teaspoonful  to  a 
quart)  can  be  employed,  and  in  the  latter  ichthyol  (10  drops  to  a 
quart)  proves  most  effective.  Not  much  can  be  expected  of  any  of 
the  antiseptics  because  the  fluid  remains  such  a  short  time  in  the- 
organ.  To  be  effective,  however,  the  patient  must  he  taught  to  wash 
out  his  or  her  own  stomach,  because,  to  be  of  any  avail,  it  must  be  done 
daily,  and  an  individual  with  other  cares  will  not  go  regularly  to  a 
physician  or  a  clinic.  Massage,  electricity,  and  the  spray  will  ac- 
complish nothing,  for  the  hypertrophied  stomach  in  its  earlier  stages, 
possesses  powerful  peristaltic  action,  which  cannot  be  increased,  and, 
when  this  stage  is  passed,  the  obstruction  has  become  so  great  that  it 
is  hopeless  to  attempt  to  overcome  it  by  increasing  the  motor  power 
of  the  stomach.  This,  of  course,  does  not  apply  to  myasthenia  without 
obstruction,  where  these  means  often  offer  the  most  available  and  effec- 
tive agencies  for  hastening  the  emptying  process. 

3.  The  medicinal  treatment,  too,  gives  us  but  little  encouragement. 
When  the  obstruction  is  largely  due  to  spasm  associated  with  hyperse- 
cretion (whether  chronic  ulcer,  as  is  generally  supposed,  exists  or  not), 
olive  oil  or  the  emulsion  of  sweet  almond  oil  often  checks  the  cramp 
and  diminishes  the  hypersecretion.  A  very  good  homemade  substitute 
for  the  pharmaceutical  preparation  can  be  made  by  grinding  a  table- 
spoonful  of  sweet  almonds,  pouring  a  cup  of  hot  water  over  them,  and 
mashing  them  thoroughly  with  a  pestle ;  this  is  then  passed  through  a 
coarse  sieve  and  drunk,  lukewarm  and  sweetened,  a  half  hour  before 
the  meal  is  taken.  There  is  always  a  powerful  suggestive  influence  in 
preparing  personally  a  medicine,  as,  for  example.  Bishop  Berkeley's. 
tar  water,  which  each  patient  could  prepare  for  himself  from  inex- 
pensive ingredients,  and,  as  the  good  divine  expresses  it,  "it  was  a 
sovereign  remedy."  Cohnheim,  who  introduced  the  olive  oil  treat- 
ment, would  have  the  patient  take  a  half  cupful  after  the  morning 
washing  or  introduce  it  into  the  stomach  through  the  tube  already  in 
situ;  later  the  patient  should  take  a  wineglassful  an  hour  before  each 
meal.  For  the  disagreeable  eructations,  resorcinol  had  been  our  favo- 
rite until  a  clinic  patient,  suffering  from  both  gastrectasia  and  rheuma- 
tism, after  the  disappearance  of  the  latter,  for  which  aspirin  was 


334  DISEASES   OF   THE  DIGESTIVE   TRACT 

given,  clamored  for  aspirin  for  his  eructations,  which  he  declared 
ceased  entirely  while  he  was  taking  that  drug.  Since  then  its  use  in 
many  other  cases  of  unpleasant  eructations  has  justified  its  employ- 
ment for  this  purpose.  We  give  it  in  0.3-gram  (5-grain)  capsules  or 
tablets  after  the  meal.  For  the  constant  heartburn  due  to  hypersecre- 
tion an  alkaline  powder  is  necessary,  and  great  ingenuity  must  be  often 
employed  to  find  one  which  is  effective,  for,  strange  to  say,  the  pa- 
tient 's  suffering  is  not  always  measured  by  the  degree  of  acidity.  Our 
favorite  is  as  follows : 

IJ     Magnesii  oxidi    30.0  or  1  ounce 

Sodii  citratis, 

Calcii  carbonatis  praecipitati,  aa   15.0  or  %  ounce 

M.  Sig. :  One-half  to  a  teaspoonful  dry  on  the  tongue,  followed  by 
a  wineglass  of  water,  a  half  hour  before  eating. 

Constipation,  if  present,  as  it  usually  is,  must  not  be  treated  by 
laxatives,  but  by  glycerine  suppositories  or  enemata,  for,  as  stated,  the 
laxatives  are  sure  to  increase  the  hypersecretion  and  pyloric  spasm. 
Very  often  the  stomach  washing,  by  hastening  and  increasing  the 
amount  of  fluid  which  enters  the  duodenum,  will  also  alleviate  the  con- 
stipation. In  spite  of  all  our  efforts,  many  cases  are  found  which  do 
not  improve,  and  an  increase  in  the  amount  of  fasting  residue,  a 
diminution  in  the  amount  of  urine,  or  a  marked  loss  of  weight,  though 
an  ample  diet  is  taken,  emphasizes  the  necessity  of  a  gastroenterostomy. 
Whether  at  the  same  time  a  pylorectomy  should  be  done  (suspicion  of 
malignancy)  must  be  left  to  the  surgeon  at  the  time  of  operation,  as 
he  has  means  of  information  with  the  lesion  before  him  which  the  in- 
ternist has  not.  It  has  probably  occurred  to  all  of  us  to  have  patients 
return  a  year  or  more  after  the  simple  gastroenterostomy  with  recur- 
rence of  symptoms,  which  a  subsequent  laparotomy  proved  to  be  due 
to  too  small  an  orifice  at  the  original  operation,  or  that  the  loop  of 
the  jejunum  leading  from  the  stomach  has  become  partially  obstructed 
by  adhesions,  but  these  instances  are  so  extremely  rare  that,  in  our  esti- 
mation, they  form  no  objection  to  the  operation. 


CHAPTER  XII 

CANCER  OF  THE  STOMACH 

We  are  so  accustomed  to  consider  cancer  of  the  stomach  as  an  object 
of  accurate  diagnosis  only  when  it  has  reached  appreciable  size,  which 
always  means  an  advanced  stage,  that  we  look  with  incredulity  on  its 
early  detection.  Still,  at  some  time  in  its  development  the  growth 
cannot  be  greater  than  a  rice  grain,  and  it  is  not  against  belief  that 
eventually  we  may  be  able  to  detect  it  at  this  early  stage.  Without 
doubt,  certain  changes  take  place  in  the  secretion  with  the  very  earliest 
advent  of  the  cancer  cells,  and  our  whole  efforts  must  be  directed  to 
the  detection  of  this  beginning  dyscrasia,  a  goal  which,  alas,  in  our 
present  state  of  knowledge  is  unattainable.  Leaving  out  of  considera- 
tion, then,  these  ideal  conditions,  we  must  take  into  account  only  those 
earliest  factors  which  will  allow  us  to  make  a  probable  diagnosis  of 
gastric  cancer,  and  those  are  beginning  ulceration  and  minute  hemor- 
rhages detected  in  the  gastric  contents  and  feces,  as  well  as  the  begin- 
ning of  changes  in  the  motor  function  of  the  attacked  organ. 

Regarding  the  duration  of  cancer  of  the  stomach,  at  two  years, 
based  on  numerous  observations,  it  is  very  probable  that  hemor- 
rhage begins  very  early  in  its  career,  and  in  all  forms  of  diges- 
tive disturbances  after  40  years  of  age  the  repeated  examination  of  the 
feces  for  blood  should  never  be  neglected.  Furthermore,  since  the  ma- 
jority of  the  growths  begin  at  the  pylorus,  or  near  it,  in  the  prepyloric 
portion  of  the  minor  curvature,  a  site  which,  by  producing  masses  of 
the  growth  in  the  lumen,  swelling  of  the  mucous  membrane,  and  spasm, 
leads  to  impaired  motility  and  stasis,  finding  food  remnants  in  the  fast- 
ing stomach  is  probably  the  second  earliest  sign  of  gastric  cancer,  and 
should  be  sought  also  in  all  digestive  disturbances  of  those  beyond  the 
age  mentioned.  The  beginning  ptosis  of  the  stomach,  produced  by  the 
growth,  also  exaggerates  the  stasis,  so  that  the  earliest  subjective  symp- 
toms of  the  patient  arise  from  retention  of  food,  plus  its  decomposition, 
induced  by  a  vigorous  growth  of  bacteria.  The  changes  in  secretion 
have  hitherto  held  the  stage  to  too  great  a  degree  in  diagnosis  of  this 
disease,  and  have  proved  a  broken  reed.  These  symptoms,  then,  aris- 
ing from  stasis  will  be  considered  in  turn,  beginning  as  far  as  pos- 

335 


336  DISEASES   OF   THE   DIGESTIVE   TRACT 

sible  with  the  earliest  and  taking  them  up  in  order  as  they  develop 
during  the  course  of  the  disease. 

Pressure  and  Distention  After  Eating. — Pressure  and  distention 
after  eating,  occurring  in  one  who  has  hitherto  had  no  digestive  diflfi- 
eulties,  are  often  the  earliest  warning  signal,  and  should  not  be  passed 
over  lightly.  These  are  particularly  suggestive  when  at  the  same  time 
the  stomach  is  found  prominent,  filling  the  epigastric  area,  hard  to  the 
touch,  and  relief  is  obtained  by  eructations  of  gaseous  or  liquid  ma- 
terial or  vomiting.  The  hindrance  to  the  emptying  of  the  stomach, 
together  with  the  distention  due  to  bacteria,  causes  these  peculiar 
symptoms.  It  happens  quite  often  that  the  objective  stasis  (by  wash- 
ing the  stomach  or  radiogram)  precedes  the  sensation  of  pressure  by 
considerable  time.  Usually  the  sense  of  fullness  is  distributed  over 
the  entire  epigastrium,  or  it  may  be  more  marked  on  the  right  in  the 
region  of  the  pylorus,  under  the  xiphoid,  or  in  the  back.  Rarely  a 
stabbing  sensation  is  experienced  under  both  costal  arches.  Generally, 
the  feeling  is  intermittent,  beginning  within  the  first  two  hours  after 
food  is  taken  and  lasts  an  hour,  though  it  may  be  more  or  less  con- 
tinuous. The  amount  and  quantity  of  the  food  (brown  bread,  greens, 
radishes,  watercress,  etc.)  exercise  a  marked  influence  on  increasing 
the  severity  of  the  pressure  symptoms,  which  differentiates  cancer  from 
nervous  dyspepsia,  where  a  small  easily  digested  meal  causes  as  much 
discomfort  as  a  larger.  The  greatest  distress  is  caused  usually  by 
meat,  and  particularly  boiled  cornbeef  on  account  of  its  coarse  fibers. 
Individual  peculiarities  play  some  role,  for  pork,  ordinarily  considered 
difficult  of  digestion,  may  sometimes  be  borne  by  these  sufferers  from 
gastric  cancer  better  than  beef,  while  some  declare  that  sweets  are  their 
undoing,  and  others  complain  of  vegetables.  True,  there  are  other  af- 
fections— especially  the  gastric  neuroses  of  women  near  the  climacteric, 
reflex  gastric  disturbance  from  cholecystitis,  esophageal  obstruction 
near  the  cardia,  benign  ulcerations  of  the  stomach,  and  hypertrophic 
cirrhosis  of  the  liver — which  produce  pressure  after  eating,  but,  com- 
ing in  those  who  boast  their  possession  of  an  excellent  digestion  all 
their  life,  it  has  an  ominous  significance.  Practically  all  of  these  con- 
ditions, except  gastric  neurosis  and  ulcer,  can  be  readily  eliminated. 
"When  an  individual  of  ripe  years,  previously  healthy,  comes  to  the 
physician  with  a  tale  of  indigestion,  accompanied  by  distress  after  eat- 
ing, increased  by  a  large  meal  of  coarse  food  which  does  not  yield  to 
simple  means,  but  is  steadily  progressive,  and  tries  to  assure  the  phy- 
sician that  it  was  brought  on  by  a  single  indiscretion  in  diet,  it  should 
not  be  regarded  or  treated  as  gastric  catarrh,  but  looked  on  with  sus- 


CANCER   OF   THE   STOMACH  337 

picion,  and  no  conclusion  should  be  reached  until  every  means  known 
has  been  employed  to  exclude  gastric  cancer. 

Eructations  and  Regurgitations. — Eructations  and  regurgitations 
are  also  manifestations  of  gastric  stasis,  though  they  may  arise  from 
gastric  neurosis.  From  occasional  "belching"  to  persistent  vomiting 
there  is  a  progressive  gradation.  They  may  occur  spontaneously,  or 
may  be  aroused  by  bending  or  by  exercise,  which  compresses  the 
stomach.  The  peculiarities  of  the  aerophagy  of  neurasthenics  have 
been  mentioned,  but  the  gaseous  eructations  of  the  cancer  patient  differ 
from  the  former  in  usually  being  noiseless,  possessing  an  odor,  and 
frequently  occurring  at  night.  Acid  ei'uctations  of  cancer  belong  to 
the  earliest  period,  long  before  the  appetite  or  general  condition  of 
the  patient  has  begun  to  suffer.  They  are  the  result  of  fermentations, 
which,  in  turn,  are  dependent  on  an  insufficiency  of  the  stomach  and 
diminished  hydrochloric  acid,  and  the  acid  fluid  is  usually  made  up 
of  the  organic  acids — butyric,  acetic,  and  lactic.  Never  should  it  be 
taken  for  granted  without  examination  that  they  are  due  to  an  excess 
of  hydrochloric  acid.  This  symptom  is  usually  associated  with  the 
emptying  of  the  stomach,  and  comes  on  two  to  three  hours  after  the 
meal,  but  may  come  at  night.  The  ingestion  of  brown  bread  or  rye 
bread  is  especially  liable  to  bring  it  on.  Instead  of  this  acid  eructa- 
tion the  patient  may  have  brought  up  a  mouthful  of  a  brackish-tasting 
fluid  (water  brash),  w'hich  must  not  be  confounded  with  excessive  se- 
cretion of  saliva,  also  a  rare  accompaniment  of  cancer.  Vomiting  is 
the  last  stage  of  regurgitation,  and  comes  late  in  the  disease,  or  may 
not  occur  at  all.  Where  the  growth  is  diffuse  and  the  stomach  much 
contracted,  this  symptom  is  liable  to  come  early  and  occur  after  the 
smallest  amount  of  fluid  is  taken.  When  the  growth  is  confined  to  the 
pylorus  and  marked  ectasia  follows,  vomiting  is  less  frequent,  but  very 
copious  when  it  occurs.  The  act  takes  place  most  often  two  hours 
after  the  hearty  meal  of  the  day,  or  may  occur  at  night.  When  it  be- 
gins in  a  healthy  individual  and  is  persistent,  it  should  not  be  at- 
tributed to  something  wiiich  "disagreed"  with  the  patient;  the  indi- 
gestion was  often  only  incidental  to  the  cancer  which  preceded  it. 
When  well  established,  vomiting  can  be  as  readily  aroused  by  a  drink 
of  cold  water  as  by  solid  food;  in  fact,  some  victims  can  take  solids 
better  than  liquids.  Another  peculiarity  often  mentioned  by  patients 
with  this  disease  is  that  all  three  symptoms — eructation,  regurgitation, 
and  vomiting — occur  more  particularly  when  they  are  lying  on  their 
right  side.  These  are  cases  where  the  growth  is  at  the  pylorus  and 
the  narrowing  is  apparently  exaggerated  in  this  position ;  at  least. 


338  DISEASES   OF   THE   DIGESTIVE   TRACT 

when  nausea  is  aroused  by  lying  on  the  right  side,  it  signifies  a  lesion 
at  the  pylorus  and  usually  of  the  organic  kind.  In  general  the  vomitus 
contains  food,  less  rarely  bile,  though  this  is  possible  where  the  growth 
is  at  the  fundus,  and,  while  blood  may  be  vomited  late  in  the  disease, 
it  does  not  occur  in  large  quantities.  The  ' '  coffee  grounds ' '  vomiting 
is  especially  significant  when  found  beset  with  numerous  lactic  acid 
bacilli,  though  it  may  be  found  in  severe  icterus,  gastric  crises,  acute 
peritonitis,  sepsis,  and  pneumonia.  Fecal  and  fetid  vomitus  signifies 
a  perigastric  abscess  from  the  growth  which  has  opened  into  the 
stomach,  or  a  fistula  into  the  colon  or  ileus  from  the  pressure  of  the 
tumor. 

Fain. — ^Pain  is  a  fairly  common  accompaniment  of  gastric  cancer, 
but  it  is  sometimes  surprising  to  see  the  disease  run  its  course  without 
any  marked  complaint  of  pain  on  the  part  of  the  patient.  This  symp- 
tom also  is  due  to  the  struggle  of  the  stomach  to  empty  itself  of  its 
contents,  and  usually  during  the  attack  one  can  see,  synchronous  with 
the  look  of  distress  on  the  patient's  face,  the  rigid  stomach  forcing  it- 
self above  the  level  of  the  abdomen.  After  eructation  the  pain  often 
ceases,  and  the  stomach  at  the  same  time  relaxes  and  becomes  soft. 
Such  a  complex  condition  invariably  means  a  growth  at  the  pylorus, 
and  is  associated  with  the  stage  where  no  marked  dilatation  of  the 
stomach  has  taken  place,  nutrition  is  but  slightly  impaired,  and  hydro- 
chloric acid  persists,  which  may  be  the  instigator  of  peristalsis  or 
pyloric  spasm.  These  intermittent  attacks  of  pain  are  the  most  sug- 
gestive symptoms  about  early  gastric  cancer,  and,  if  more  attention 
were  paid  to  them,  there  would  not  be  so  many  false  diagnoses  of 
gastric  catarrh  made,  for  the  latter  disease  uncomplicated  is  not  ac- 
companied by  pain.  Curiously  enough,  pain  becomes  a  less  and  less 
important  feature  as  the  disease  progresses,  being  thus  in  marked  con- 
trast to  the  rapid  growth  of  the  tumor.  This  is  probably  due  to  the 
adaptation  of  the  stomach  to  the  internal  pressure  by  dilatation, 
diminution  of  its  peristalsis,  and  obliteration  of  hydrochloric  acid- 
producing  glands.  The  pain  is  rather  bizarre  in  its  position  and  direc- 
tion of  radiation,  usually  of  colicky  character,  but,  still,  well-defined 
types  can  be  recognized.  There  may  be  the  right-sided  variety,  which, 
beginning  at  the  right  costal  arch,  streams  to  the  corresponding  por- 
tion of  the  back  and  to  the  right  shoulder  blade,  markedly  resembling, 
as  can  be  seen,  gallstone  colic.  There  may  be  girdle  pain,  beginning 
under  the  xiphoid  and  extending  to  both  sides  along  the  costal  arches, 
to  meet  in  the  back.  Pain  may  begin  in  the  epigastrium  and  extend  to 
the  left  nipple  and  left  shoulder  blade.     Again,  the  pain  may  be  felt 


CANCER  OF   THE   STOMACH  339 

almost  exclusively  in  the  lumbar  region,  and  can  be  distinguished 
from  the  pain  of  retroperitoneal  metastasis  of  the  glands  or  cancer  of 
the  pancreas  only  by  the  fact  that  the  former  is  aroused  by  taking  food, 
while  the  latter  two  are  liable  to  be  constant.  While  ordinarily  these 
pains  begin  two  to  three  hours  after  food,  if  deferred  to  six  or  seven 
hours,  it  should  not  mislead  one  into  regarding  the  duodenum  as  the 
site  of  the  growth. 

Appetite. — The  appetite  is  usually  affected  early,  and  patients  ex- 
hibit a  great  distaste  for  food,  especially  for  meat.  Still,  this  is  not  in- 
variably so,  and  the  maintenance  of  an  excellent  appetite  should  never 
be  utilized  as  a  diagnostic  point  against  the  presence  of  cancer,  for  the 
medullary  variety  without  stenosis,  or  a  rapid  ulceration  of  a  scirrhous 
tumor  at  the  pylorus,  is  not  inconsistent  with  an  excellent  appetite. 
Thirst  is  usually  increased,  which  has  some  diagnostic  value  in  cancer 
as  against  neurosis,  for  in  the  latter  case  patients  often  state  they 
never  care  to  drink  except  possibly  at  mealtime.  This  desire  for  fluids 
is  as  prevalent  in  those  who  do  not  vomit  as  in  those  who  do,  so  that 
the  progressive  anemia  may  be  regarded  as  a  cause,  since  this  peculi- 
arity is  often  noted  in  pernicious  anemia.  As  the  means  of  physical 
examination  and  the  findings  have  been  discussed  fully  in  Chapter 
IV  (page  89),  it  will  be  only  necessary  here  to  briefly  call  attention 
to  the  fact  that  in  comparatively  few  cases  can  the  tumor  be  felt,  at 
least  at  a  period  when,  if  anything  is  to  be  done,  we  must  act.  Hence 
we  must  rely  on  other  physical  findings,  such  as  the  "ballooning"  of 
the  stomach,  which  is  often  so  marked  that  its  outline  may  be  seen, 
or  at  least  the  lower  border  readily  felt  by  the  palpating  fingers. 
During  this  process  eructations  of  gas  occur,  and  the  organ  may  be 
felt  to  collapse  under  the  fingers.  Visible  peristalsis  is  another  ex- 
cellent guide,  whose  interpretation  is  pyloric  stenosis,  but  it  can  be 
utilized  with  other  factors  as  meaning  cancer.  Epigastric  pulsations 
are  to  be  considered  of  great  value  in  diagnosis  of  malignant  growth 
resting  on  the  aorta,  provided  that  the  stomach  can  be  demonstrated 
to  be  under  the  visible  pulsations  and  not  below  them,  as  in  gastrop- 
tosis.  When  this  pulsation  is  associated  with  a  murmur  heard  with 
the  stethoscope  over  the  epigastrium,  systolic  in  time,  exaggerated  by 
pressure  of  the  bell,  and  heard  loudly  in  deep  expiration,  it  gains  enor- 
mously in  diagnostic  value.  Often  the  thickened  pylorus  can  be  felt 
during  contraction,  and  under  the  palpating  fingers  fluid  can  be  felt 
to  spurt  or  gurgle  through  it.  This,  however,  can  be  utilized  in  favor 
of  cancer  only  when  stasis  has  been  demonstrated  and  there  is  blood  in 
the  feces.     The  tumor,  when  palpable,  may  assume  many  shapes.     The 


340  DISEASES   OF    THE   DIGESTIVE   TRACT 

small  billiard  ball  variety  may  lie  to  the  right  of  the  median  line,  just 
above  the  navel,  but  be  felt  best  when  the  patient  lies  on  the  left  side ; 
its  attachment  to  the  stomach  is  often  indicated  by  the  fact  that,  when 
pressed,  regurgitation  by  the  patient  often  takes  place  and  the  spurt- 
ing can  be  felt  easily  under  the  growth. 

Associated  Symptoms. — Associated  symptoms,  having  reference  to 
other  organs,  are  often  found  and  can  be  utilized  in  the  early  diagnosis 
of  gastric  cancer.  Among  these  is  the  marked  atrophic  changes  in 
the  tongue,  which  demonstrate  themselves  in  the  form  of  a  smooth, 
slimy,  paper-like  surface,  either  confined  to  the  middle  or  extending 
generally  over  its  entire  area.  These,  apart  from  pernicious  anemia, 
where  they  are  sometimes  found,  are  pretty  closely  confined  to  the 
former  disease.  A  coated  tongue  is  a  rare  concomitant  of  cancer, 
which  is  probably  explained  by  the  atrophy  mentioned  above.  De- 
cayed teeth  are  commonly  found,  and  the  poorly  masticated  food  and 
exuberant  growth  of  bacteria  associated,  which  are  necessarily  swal- 
lowed, may  play  a  part  in  the  causation  of  gastric  cancer.  Constipa- 
tion is  usually  found,  or  this  may  alternate  with  diarrhea.  Cases 
which  are  suspected  of  gastric  cancer,  in  which  the  latter  symptom  is 
persistent,  usually  turn  out  to  be  pernicious  anemia.  Occasionally  a 
rather  profuse  hemorrhage  from  the  growth  may  cause  diarrhea,  its 
disintegration  with  copious  production  of  pus,  or  the  establishment  of 
a  fistula  between  the  stomach  and  the  colon  after  the  growth  en- 
croaches on  the  latter.  Constipation  is  the  rule,  however,  and  also  a 
very  early  sign,  and,  when  a  very  elderly  person  suffering  from  indi- 
gestion becomes  suddenly  markedly  constipated,  gastric  cancer,  should 
be  thought  of  and  excluded  by  the  most  careful  examination.  ' '  Consti- 
pated old  age,"  the  slogan  of  a  popular  nostrum,  often  has  a  sinister 
meaning,  and  is  not  so  lightly  overcome  as  the  proprietors  would  have 
us  believe.  It  is  curious  to  note  that  this  form  of  constipation,  associ- 
ated with  malignant  disease  of  the  stomach,  is  immediately  overcome 
by  a  gastroenterostomy,  so  that  it  is  purely  of  gastric  origin.  In- 
testinal rigidity  in  sympathy  with  the  gastric  variety  is  a  rare  occur- 
rence, but  a  mass  of  metastatic  glands  in  Douglas '  pouch  may  produce 
so  much  obstruction  that  a  true  stenosis  exists,  and  the  violent,  visible 
peristalsis  may  lead  us  to  think  that  this  is  the  primary  site  of  the 
growth.  This  form  usually  goes  also  with  fluid  in  the  abdomen  from 
invasion  of  the  peritoneum,  and  may  require  tapping  before  the  masses 
can  be  felt,  as  in  a  case  recently  under  our  observation.  This  condi- 
tion will  not  be  so  often  taken  for  a  rectal  cancer  if  we  examine  the 
mucous  membrane  of  the  lower  segment  of  the  intestine,  which  we 


CANCER   OF   THE   STOMACH  341 

shall  find  intact,  the  pressure  coming  from  the  outside.  The  discovery 
of  supraclavicular  metastases  in  the  glands  on  the  left  side  would  clear 
up  this  question  in  an  instant.  The  invasion  of  the  peritoneum  may  be 
purely  local  or  general,  even  in  young  persons.  R.  Schmidt  reports  its 
presence  in  a  girl  of  18  years,  originating  from  a  medullary  cancer  of 
the  greater  curvature,  established  by  autopsy ;  hence  we  should  not  be 
satisfied  too  early  with  the  diagnosis  of  tubercular  peritonitis.  Sub- 
phrenic abscess  on  the  left  side  is  often  a  complication  by  which  tender- 
ness under  the  left  costal  border  and  obliteration  of  the  sulci  between 
the  ribs  by  the  pressure  of  the  abscess  is  not  uncommon.  The  left 
pleura  may  also  become  involved,  and  the  abscess  sometimes  break  into 
the  corresponding  pleural  cavity.  When,  at  the  last  stage  of  the 
cancer,  perforation  into  the  peritoneal  cavity  takes  place,  chills,  col- 
lapse, and  general  abdominal  tenderness  announces  that  fact,  as  in  a 
case  of  ours  already  described  under  the  consideration  of  cancer  en- 
grafted on  ulcer  (page  310).  Perhaps  the  most  common  complication 
of  gastric  cancer  is  the  invasion  of  the  liver,  and  this  usually  takes 
place  without  jaundice.  If  suspicions  of  a  gastric  growth  is  aroused 
and  jaundice  is  a  marked  feature,  it  is  more  likely  to  be  confined  to  the 
pancreas,  or,  more  rarely,  the  duodenum.  Although  this  process  of 
metastasis  in  the  liver  may  be  painless,  yet  there  are  other  cases  where 
the  invasion  is  excessively  painful,  and,  when  there  is  temperature, 
may  lead  one  to  think  he  has  to  do  with  a  cholecystitis  or  hepatic  ab- 
scess. When  the  tumor  masses  are  largely  confined  to  the  left  lobe 
and  cause  a  marked  depression  and  advancement  of  the  liver's  edge, 
these  metastases  may  be  mistaken  for  the  gastric  tumor  itself.  The 
early  presence  of  hydremic  conditions  of  the  blood  and  lowering  of  the 
circulatory  tonus  must  be  made  responsible  for  the  presence  of  moder- 
ate edema,  which  is  less  marked  over  the  shins  than  over  the  internal 
malleoli,  and  particularly  the  sacrum ;  hence  these  points  should  never 
be  neglected  when  the  tibias  fail  to  respond.  In  women  metastases  in 
the  ovaries  are  not  uncommon,  and  have  led  to  useless  operations. 
The  color  of  the  skin  is  either  pale-gray,  resembling  closely  that  seen 
in  tuberculosis,  or  has  a  yellowish  tinge,  when  it  reminds  one  of  per- 
nicious anemia.  In  the  latter  case  both  bilirubin  and  urobilin  are 
absent  from  the  urine,  so  that  the  color  cannot  be  of  hepatic  origin. 

Physical  and  chemical  findings  in  cancer  of  the  stomach  have  been 
fully  discussed  under  the  respective  chapters,  but  perhaps  a  resume 
will  not  be  out  of  place.  An  individual  over  10,  with  a  pasty  or  lightly- 
yellow  tinged  color,  who  has  been  losing  flesh,  has  a  prominent  epigas- 
trium, with  marked  resistance  under  the  right  costal  border  near  the 


342  DISEASES   OF   THE   DIGESTIVE   TRACT 

median  line,  due  to  spasm  of  the  rectus,  whether  a  mass  can  be  found 
or  not,  with  an  enlarged  flaccid  stomach  or  a  small  firm  one,  whose 
lower  border  can  be  distinctly  felt,  with  occasional  intermittent  in- 
creases and  diminutions  of  rigidity,  and  a  slight  edema  over  the  in- 
ternal malleoli,  may  be  said  to  be  strongly  suspicious  of  gastric  cancer. 
If,  in  addition  to  this,  he  shows  moderate  stasis,  sarcinaB  with  dimin- 
ished hydrochloric  acid,  or  lactic  acid  and  its  bacilli  (long,  threadlike), 
with  no  hydrochloric  acid,  "occult"  blood  in  the  stool  and  possibly  the 
"thread"  bacilli,  or  sarcinae  also,  such  an  individual  should  be  sub- 
jected to  an  exploratory  operation,  perhaps  after  being  x-rayed,  with- 
out any  hesitancy. 

In  our  opinion,  when  we  have  watched  for  a  well-defined  tumor, 
profuse  hemorrhage,  or  absolute  loss  of  hydrochloric  acid,  we  have 
waited  too  long,  and  operation  is  practically  useless  except  for  relief 
of  the  pain  and  stasis.  On  account  of  the  great  importance  of  detect- 
ing this  disease  early,  perhaps  a  word  or  two  more  in  regard  to  diag- 
nosis will  not  come  amiss.  Stasis  may  be  due  to  obstruction  at  the 
pylorus,  caused  by  either  ulcer  or  cancer,  and  many  of  the  symptoms 
mentioned,  including  "occult"  blood,  may  come  from  either.  Then 
our  aspiration  is  to  reach  a  diagnosis  before  a  tumor  appears,  a  factor 
which  promptly  separates  the  two  diseases.  Hence  reliance  must  be 
placed  largely  on  the  persistence  of  the  normal  or  increased  hydro- 
chloric acid  and  digestive  leucocytosis,  as  well  as  the  absence  of  the 
peculiar  color  of  malignant  disease.  A  sufferer  from  chronic  ulcer 
with  stenosis  may  show  excessive  pallor,  but  never  the  yellowish  tinge 
so  characteristic  of  malignant  disease,  no  edema,  no  metastases,  though 
it  must  be  acknowledged  that  the  latter  are  not  found  in  the  early 
stage  of  cancer,  nor  a  tryptophan  reaction.  Then,  chronic  gastritis 
possesses  certain  similarities  with  cancer  in  the  absence  of  hydrochloric 
acid,  but  never  signs  of  stenosis,  sarcinae,  lactic  acid  bacilli,  or  pain. 
Physicians  have  been  too  prone  to  call  these  early  symptoms  of  in- 
digestion in  elderly  people  gastric  catarrh,  resting  comfortably  on  that 
opinion  until  increasing  stasis  warns  them  that  malignant  disease  lies 
at  the  bottom  of  the  difficulty;  in  fact,  gastric  catarrh,  though  com- 
monly found  at  autopsy,  when  patients  never  suffered  digestive  diffi- 
culties during  life,  is  rarely  alone  the  cause  of  much  discomfort,  and 
complaints  made  by  the  patient  usually  arise  from  the  antecedent  dis- 
ease (cirrhosis  of  the  liver,  regurgitant  heart  disease,  etc.) .  To  us  per- 
nicious anemia  has  often  proved  the  most  difficult  to  disentangle  from 
gastric  cancer  because  frequently  accompanied  by  the  ominous  color, 
loss  of  hydrochloric  acid,  and  edema.     Apart  from  the  distinction  by 


CANCER   OF   THE    STOMACH  343 

means  of  blood  examination  between  a  primary  and  secondary  anemia, 
we  have  other  differences  which  aid  us,  and  R.  Schmidt  has  arranged 
them  in  the  following  table : 

ANEMIC    TYPE   OF   GASTRIC    CANCER.  PERNICIOUS   ANEMIA 

Constipation  Long  continued  diarrhea 

Enlarged  spleen,  rare    Common 

Pain  on  pressure  over  lower  half  of  sternum, 

rare    Common 

"Occult"  blood  in  stool No  blood  in  stool 

Lactic  a«id  bacilli  in  stool,  common Only  rarely 

Cancer  of  the  gallbladder  is  also  difficult  to  differentiate  from 
primary  gastric  cancer  because,  by  pressure  on  the  pylorus  or 
duodeum  or  extension,  we  have  anorexia,  ectasia,  increased  gastric 
peristalsis,  "coffee  ground"  vomiting,  achlorhydria,  and  sarcinse. 
This  is  particularly  true  when  jaundice  is  not  a  marked  feature,  and 
sometimes  happens  when  the  disease  is  confined  strictly  to  the 
gallbladder.  When,  however,  jaundice  is  the  main  feature,  but  all 
these  symptoms  and  findings  relative  to  the  stomach  are  present,  as 
in  a  case  recently  seen  in  the  clinic,  accompanied  by  invasion  of  the 
liver,  gallbladder  cancer  is  primary.  Cancer  of  the  cardial  end  of  the 
esophagus  often  proves  a  stumblingblock  because  the  obstruction  may 
not  be  sufficient  to  be  detected  readily  by  the  tube  or  sound,  and  no 
evidence  of  stasis  or  increased  peristalsis  is  present ;  difficulty  in  swal- 
lowing may  not  be  marked,  and  one  has  only  the  increasing  loss  of 
weight  and  cachexia.  In  such  a  case,  however,  under  my  observa- 
tion hydrochloric  acid  was  lacking.  The  importance  of  a  correct  diag- 
nosis is  seen  at  a  glance,  for  no  one  would  for  an  instant  recommend 
an  operation  if  assured  that  the  growth  was  at  that  point,  unless  for 
the  purpose  of  staying  death  by  starvation,  since  there  is  no  pain 
naturally  from  increased  peristalsis. 

Treatment. — The  treatment  other  than  surgical  is  the  most  hopeless 
and  unsatisfactory  task  that  falls  to  a  physician.  We  can  only  hope 
to  relieve  pain  by  treatment,  which,  as  it  is  largely  due  to  the  struggle 
of  the  stomach  to  empty  itself,  must  be  dietetic  in  the  sense  that  only 
the  most  finely  divided  food  is  allowed  to  enter  it,  nor  must  this  be 
wholly  liquid,  for.  when  the  secondary  dilatation  has  taken  place,  over- 
distention  is  a  thing  to  be  avoided.  Then,  again,  when  the  state  of 
achlorhydria  is  reached,  we  must  restrict  the  protein  to  the  smallest 
possible  limit,  for  the  whole  burden  of  its  digestion  is  thrown  on  the 
pancreas.  The  earlier  stages,  when  stasis  does  not  exist  and  the 
diagnosis  is  assured,  if  the  patient  refuse  operation,  or  an  x-ray  exam- 


344  DISEASES   OF   THE   DIGESTIVE   TRACT 

ination  indicate  that  the  growth  is  diffuse  and  not  removable,  we  must 
employ  the  diet  list  given  on  page  302  for  chronic  gastritis  with  absence 
of  hydrochloric  acid.  When  retention  begins  to  be  marked,  we  may  em- 
ploy the  dietary  suggested  under  ectasia,  with  modifications  adapted  to 
the  failing  peptic  power.  This  diet  can  be  found  under  ectasia  with 
absence  of  hydrochloric  acid  (page  331).  Small  and  numerous  meals 
are  desirable,  and  condiments  should  be  used  freely  to  stimulate  a 
desire  to  eat  and  whip  the  flagging  energy  of  the  peptic  glands  into 
activity.  Fat  must  be  restricted  to  butter  and  cream,  especially  when 
the  motility  begins  to  be  impaired.  Meat  should  be  limited  to  the 
white  meat  of  chicken  and  lean  fish  (cod,  haddock,  etc.)  on  account  of 
the  excessive  distaste  of  patients  for  meat.  Vegetables  in  puree  form 
and  mush  made  from  various  grains,  taken  with  milk  and  sugar,  must 
be  the  mainstay  of  our  diet.  Milk,  eggs,  and  custards  will  prove  grate- 
ful to  the  patient  and  are  nutritious,  but  the  first  must  be  fortified 
by  various  concentrated  foods  and  made  palatable  by  tea,  cocoa,  coffee, 
brandy,  and  whisky.  On  account  of  the  rapid  loss  of  weight,  only 
moderate  exercise  should  be  allowed,  and  much  of  the  patient's  time 
should  be  passed  on  a  couch,  since  we  wish  to  restrict  metabolism  to 
the  most  limited  degree.  As  to  medicinal  treatment,  no  drug  has  ever 
been  discovered  which  has  the  slightest  effect  in  staying  the  progress 
of  the  disease.  In  the  early  years  of  our  practice  (twenty-six  years 
ago)  we  heard  much  of  the  merits  of  condurango  as  a  cure  for  gastric 
cancer,  but,  at  the  most,  it  can  only  temporarily  improve  the  appetite. 
It  may  be  given  either  as  an  infusion,  like  digitalis,  in  a  strength  of  15 
grams  to  180  c.c,  of  which  the  dose  is  a  tablespoonful,  or,  better,  since 
more  convenient,  in  the  following  guise : 

IJ     Fluidextracti    condurango    30.0    or    1    ounce 

Sig. :     Twenty  drops  in  water  before  meals  three  times  daily. 

Or 

1^     Infusi  condurango 15.0:  180  or  ^^:  6  ounces 

Acidi  hydrochlorici  diluti 6.0  or  11^  drams 

Syrupi  sacchari,  q.s.  ad 200.0  or  7  ounces 

M.  Sig. :     Tablespoonful  before  meals  three  times  daily. 

The  various  stomachics  may  be  tried  to  increase  the  appetite  and 
give  encouragement  to  the  patient,  of  which  the  orexin  tannate  in  ^^ 
gram  doses  may  be  given  twice  daily  an  hour  before  meals,  followed  by 
a  glass  of  water.  As  mentioned,  the  more  convenient  way  is  to  use  the 
orexoids  of  Merck,  tablets  of  0.25  gram  (4  grains),  of  which  2,  well 
pulverized,  are  to  be  taken  twice  daily  under  the  same  conditions. 


CANCER   OF   THE   STOMACH  345 

Among  the  complications  which  cause  great  distress  to  the  patient,  but 
which  are  rarely  sufficiently  profuse  to  endanger  life,  are  the  attacks 
of  hemorrhage  from  the  stomach.  In  general,  the  same  treatment 
should  be  followed  as  in  ulcer — rectal  feeding  and  the  hypodermic  in- 
jection of  the  contents  of  1  ampule  of  aseptic  ergot.  To  control  the 
nausea,  one  can  give  chloroform  (3  to  5  drops)  on  a  small  piece  of  ice, 
or  10  drops  of  a  1  per  cent  solution  of  cocaine  hydrochloride  in  the 
same  way,  or  resorcinol  combined  with  laudanum,  which  also  controls 
the  pain,  as  in  the  following : 

IJ     Resorcinolis   2.0  or  l^  dram 

TincturjE  opii  deodorati 5.0  or  I14  drams 

Syrupi  aurantii 30.0  or  1  ounce 

Aquae  destillatae,  q.s.  ad 180.0  or  6  ounces 

M.  Sig. :     Teaspoonful  every  four  hours. 

Later  we  have  to  combat  in  most  cases  the  pain,  and  one  must  begin 
slowly  to  use  narcotics,  for  the  demand  steadily  increases  until  often 
enormous  doses  are  required  to  keep  the  patient  comfortable.  At  first 
employ  codeine,  of  which  the  Newer  Formulary  provides  an  elegant 
preparation,  syrupus  codeinae,  that  in  only  teaspoonful  doses  will  pro- 
duce much  effect.  This,  as  personal  observation  has  shown,  will  keep 
the  patient  comfortable  for  a  long  time.  Anesthesin  in  0.2-gram  (3- 
grain)  doses  in  the  bonbons  put  up  by  the  manufacturers  is  also  a  mild 
alleviative  of  pain  and  ranks  with  codeine.  Comparing  favorably  with 
these  in  efficiency  is  the  following : 

IJ     Orthoformi, 

Aspirini,   aa 10.0   or   1^  ounce 

M.     Fac  in  capsulas  XX. 

Sig. :     One  capsule  half  an  hour  before  meals  three  times  daily. 

Eventually,  however,  we  must  have  recourse  to  morphine,  and  for 
a  time  suppositories  of  morphine  sulphate,  0.015  (i/4  grain),  and  atro- 
pine sulphate,  0.0005  (/42o  grain),  will  suffice,  but,  unless  necrosis  of 
the  growth  frees  the  passage,  the  dose  of  morphine  by  suppository  will 
have  to  be  doubled,  and  soon  the  hypodermic  syringe  will  be  the  only 
weapon  which  will  stay  the  suffering.  This  is  fully  justified,  but  fol- 
low the  old-school  motto,  "festinamus  lente, "  and  do  not  be  in  too 
much  of  a  hurry  to  employ  the  more  vigorous  means.  The  only  phys- 
ical treatment  of  any  avail  is  the  gastric  lavage,  and  then  only  in  the 
early  stages.  It  makes  no  difference  whether  the  stagnation  is  due  to 
narrowed  pylorus  or  to  diffuse  medullary  growth  of  the  fundus,  which 
also  causes  a  marked  gastric  insufficiency.     Lavage  in  the  early  stages 


346  DISEASES   OP    THE   DIGESTIVE   TRACT 

removes  the  decomposing  contents,  relieves  the  nausea,  checks  the 
vomiting,  and,  it  seems  to  me — though  the  statement  is  based  wholly 
on  empiric  knowledge — defers  the  fatal  termination.  In  the  later 
stages  the  patient  is  so  weak  and  the  amount  of  food  taken  so  small 
that  it  does  not  seem  worth  while  to  torment  him  with  the  tube.  Most 
patients  readily  learn  to  wash  out  their  own  stomachs,  and  fly  to  it  for 
relief  from  their  discomfort,  and  here  just  a  word  of  caution :  while 
direct  transference  of  cancer  cells  has  never  been  proven,  still,  when  a 
tube  of  ours  has  entered  a  stomach  which  contains  a  malignant  growth, 
the  patient  becomes  the  possessor  of  the  tube.  Of  course,  tubps  are 
always  thoroughly  sterilized  after  employment,  but  in  cancer  there  is 
always  a  repugnance  against  ever  using  that  tube  on  another.  A 
lavage  is  not  always  necessary,  for  the  mere  introduction  of  the  tube 
and  removal  of  the  accumulated  contents  in  the  stomach  often  affords 
great  relief.  Our  earliest  recollection  of  Boas'  clinic  was  to  see  the 
patients  enter,  be  given  a  tube,  and  then  often  fill  a  pail  half  full  of 
accumulated  stagnant  residue,  with  every  evidence  of  great  relief. 
Some  patients,  however,  can  easily  excite  the  center  of  vomiting  by 
passing  the  finger  down  the  throat  and  in  this  way  empty  their 
stomachs.  Massage  should  never  be  employed  in  the  vain  hope  of  in- 
creasing motility  of  the  stomach  in  this  disease,  for  hemorrhage  may  be 
easily  incited  in  this  way.  Mineral  waters  should  never  be  employed 
under  the  vain  hope  of  removing  mucus  or  ' '  cleaning ' '  out  the  stomach 
fi-om  its  stagnating  residue.  If  employed,  the  patient  is  invariably 
worse. 


CHAPTER  XIII 

ENTEROPTOSIS  (SPLANCHNOPTOSIS) 

This  term  indicates  that  all  the  abdominal  organs  have  left  their 
customary  site  and  assumed  a  new  one,  usually  below  the  former,  but 
they  may  also  undergo  simultaneous  lateral  change  of  position.  Two 
groups  of  cases  can  be  readily  distinguished  as  possessing  this  con- 
dition : 

1.  The  women  who  from  frequent  childbearing,  removal  of  ab- 
dominal tumors — in  fact,  from  any  laparotomy — lose  the  tone  and 
elasticity  of  the  abdominal  walls,  which  aid  in  the  support  of  the  organs, 
and  allow  them  to  fall. 

2.  The  second  group  comprises  both  men  and  women,  even  children, 
who  are  born  with  narrow  chests,  too  small  to  allow  lungs,  heart, 
stomach,  colon  flexures,  and  kidneys  in  the  thorax  within  the  limits  of 
the  costal  arches,  so  that  the  organs  below  the  low-lying  diaphragm 
are  forced  downward.  In  these  individuals  there  is  also  a  peculiar 
lack  of  muscular  tone,  which  persists  long  after  muscular  develop- 
ment should  have  reached  its  acme,  but  changed  intraabdominal  pres- 
sure has  nothing  to  do  with  the  condition  as  in  the  former.  The  dis- 
tinction between  the  two  classes  is  brought  out  more  fully  by  their 
clinical  history  and  groups  of  symptoms  than  by  the  anatomical  and 
pathological  differences.  Of  course,  there  must  be  insensible  grada- 
tions from  one  form  to  the  other,  for  the  woman  with  hereditary  en- 
teroptosis  will  necessarily  have  this  exaggerated  by  childbearing  and 
the  organs  will  descend  still  lower,  but  in  no  case  does  the  hereditary 
form  reach  the  excessive  degree  of  displacement  that  the  acquired  will. 
In  marked  cases  of  the  latter,  one  is  reminded  of  the  kangaroo,  for  all 
the  woman's  abdominal  organs  are  apparently  carried  in  a  pouch,, 
extending  sometimes  halfway  to  the  knees,  and,  still,  such  an  individual 
will  often  not  suffer  half  as  much  as  the  possessor  of  a  moderate  degree 
of  congenital  ptosis.  Many  theories  have  been  advanced  for  the  lower- 
ing of  the  abdominal  organs,  one  of  which  is  that  the  lungs  themselves 
exert  a  pull  on  them,  thereby  lessening  the  amount  of  weight  to  be  sus- 
tained by  the  abdominal  walls  and  the  pelvis ;  hence  the  more  powerful 
the  chest  is  developed,  the  stronger  the  pull  of  the  lungs  by  their  con- 

347 


348  DISEASES  OF   THE   DIGESTIVE   TRACT 

traction  on  the  diaphragm  and  the  organs  immediately  below  it.  In 
all  eases  of  enteroptosis  Mathes  claims  he  found  a  flat,  weak,  and  de- 
pressed thorax,  which  narrowed  the  pleural  cavity  and  diminished  the 
lungs'  elasticity.  The  subsequent  course  is  the  flattening  of  the  dia- 
phragm, the  liver  begins  to  drop,  and  the  other  organs  must  lead  the 
way.  All  this  is  aided  by  the  muscular  weakness  of  the  individual, 
who  cannot  oppose  vigorously  developed  abdominal  walls  to  the  descent 
of  the  organs  upon  it  and  the  extra  burden  of  support.  Such  theoriz- 
ing would  be  but  little  better  than  that  of  medieval  times,  when 
ecclesiastics  discussed  how  many  devils  could  dance  upon  the  point  of 
a  needle,  were  it  not  so  essential  to  discover  the  mechanical  difliculty 
so  as  to  oppose  a  mechanical  aid.  Strauss  regards  the  congenital 
enteroptosis,  so-called,  as  a  persistence  of  the  infantile  type  of  body, 
and  many  cases  in  our  experience  have  impressed  themselves  upon  us 
as  instances  of  arrested  development  rather  than  of  general  muscular 
weakness.  One  case,  a  young  lady  of  17  years,  with  marked  ptosis  of 
stomach  and  colon,  existing  since  birth,  had  the  appearance  of  a  boy 
of  12.  She  had  menstruated  only  once,  the  breasts  were  undeveloped, 
but,  with  the  narrow  chest,  sloping  ribs,  and  acute  epigastric  angle, 
the  girl's  muscles  were  well  developed,  and  she  could  play  a  vigorous 
game  of  tennis.  Regurgitation  of  food  and  persistent  constipation^ 
associated  with  periods  of  depression,  made  life  a  burden  for  her,  and 
a  cure  was  effected  only  by  a  gastrocolic  suspension. 

In  connection  with  the  acquired  form  of  enteroptosis,  much  has  been 
said  pro  and  eon  in  regard  to  its  causation  by  corsets.  The  outcome  is 
that  a  well-fitting  article  has  no  effect  on  the  muscular  well-built 
woman,  but  a  most  decidedly  deleterious  effect  on  the  weakling,  push- 
ing the  already  mildly  prolapsed  organs  still  further  down.  This  is 
true  not  only  of  corsets,  but  also  of  the  bands  and  belts  by  which  the 
lower  garments  of  women  are  suspended  above  the  hips,  which  are 
equally  as  mischievous.  Patients  will  say  that  these  are  not  tight,  but, 
if  so,  why  do  not  the  skirts  drop  off  over  the  hips,  as  they  would  do  if 
no  belt  were  used  ?  It  was  the  contribution  of  0.  Kraus,  who  studied 
the  subject  with  the  x-ray,  to  show  us  what  actually  happened  when 
the  corsets  were  put  on.  The  lower  portion  of  the  thorax  is  narrowed 
(particularly  anteroposteriorly),  the  arch  of  the  lumbar  region  is  ex- 
aggerated, and  the  diaphragm  is  forced  downward  more  on  the  right 
than  on  the  left;  the  abdomen  is  elongated  upward,  the  thorax  short- 
ened, the  lower  borders  of  the  lungs  stand  higher  and  their  volume 
is  diminished,  the  heart  is  raised,  the  cardia  is  forced  higher,  and  the 
lower  border  of  the  stomach  is  depressed.     A  muscularly  developed 


ENTEROPTOSIS    (SPLANCHNOPTOSIS)  349 

body  will  reassume  its  natural  position  on  account  of  its  elasticity  as 
soon  as  the  corset  is  laid  aside,  but  a  fra^le  one  soon  assumes  this 
artificial  shape,  much  as  do  the  feet  of  the  Chinese  women  after  months 
of  compression.  Nothing  is  ever  accomplished  permanently  by  exag- 
geration, and  the  wild  statement  that  corsets  cause  this  condition  is, 
of  course,  ungrounded,  for  we  would  have  no  explanation  for  this  con- 
dition in  men,  nor  in  women  who  have  never  worn  corsets.  By  those 
congenitally  affected  and  by  those  who  have  acquired  it  by  childbear- 
ing,  corsets  and  bands  around  the  waist  should  never  be  worn.  It  is 
not  always  wise  to  jump  at  the  conclusion  when  an  acquired  enterop- 
tosis  is  discovered  that  this  accounts  for  all  the  symptoms,  for  in  the 
clinics  hundreds  of  this  form  will  pass  through  your  hands  without  a 
symptom,  except  possibly  constipation.  Kyphosis,  also,  is  often  asso- 
ciated wuth  enteroptosis,  the  stomach  frequently  being  found  as  low 
down  as  the  pubes  without  symptoms  pertaining  to  this  condition, 
though  in  one  case,  reported  at  the  time,  ulcer  was  found  and  relieved 
by  operation.  Another  cause  for  this  condition  was  the  rabid  anti- 
obesity  cures,  now  fortunately  given  up,  by  which  fifteen  to  seventeen 
pounds  were  removed  in  a  fortnight,  as  in  the  ease  of  a  lawyer  of  our 
acquaintance,  who  spent  a  year  recovering  from  the  effects  of  it. 

Symptoms. — The  symptoms  must  be  divided  into  two  classes — those 
which  pertain  to  the  digestive  organs  themselves  and  those  various 
nervous  manifestations  which  probably  are  a  part  of  the  general  com- 
plex of  which  the  ptosed  organs  form  another;  in  other  words,  myas- 
thenia universalis.  The  general  appearance  of  the  patient  often  dis- 
closes his  ailment.  An  apathetic  look ;  a  pale,  transparent  skin ;  a 
narrow  chest,  with  ribs  running  directly  and  sharply  downward ;  broad 
intercostal  spaces,  and  often  the  floating  unattached  tenth  rib;  the 
narrow  epigastric  angle,  and  the  utter  absence  of  adipose  tissue  under 
the  skin,  all  form  the  stigmata  of  this  condition.  The  "floating 
tenth,"  of  which  so  much  has  been  made  by  Stiller,  is  not  a  constant 
concomitant  of  this  condition  (congenital  form),  and,  furthermore,  at- 
tachment to  the  sternum  may  vary  all  the  way  from  firm  to  a  ligamen- 
tous union,  so  slight  that  it  is  difficult  to  differentiate  it  from  freedom. 
Then,  sometimes  one  finds  the  free  tenth  rib  without  enteroptosis.  It 
would  seem  to  us  that  its  lack  of  attachment  was  more  dependent  on  the 
peculiar  position  of  the  ribs,  which  run  downward  at  such  a  sharp 
angle ;  this  leaves  the  terminus  of  the  tenth  rib  at  such  a  distance  from 
the  sternum  that  attachment  is  difficult.  As  the  position  of  the  ribs 
causes  the  narrow  chest  and  the  latter  the  descent  of  the  stomach,  one 
can  easily  see  the  relation,  but  no  necessarily  rigid  correlation  of  the 


350  DISEASES   OF   THE   DIGESTIVE   TRACT 

three  factors.  One  noticeable  symptom  about  all  sufferers  from  ptosis 
is  their  tendency  to  malnutrition,  which  manifests  itself  as  a  moderate 
degree  of  emaciation.  Even  small  children  with  this  abnormality  are 
very  nervous,  as  the  parents  say,  or  irritable,  as  we  would  call  it,  and, 
in  spite  of  every  effort  in  the  way  of  increasing  nourishment,  fail  to 
keep  pace  with  the  development  corresponding  to  their  age.  These 
children  also  suffer  from  lack  of  appetite,  which  is  interpreted  as  a 
* '  weak  stomach, ' '  are  easily  tired,  and  at  puberty  or  afterward  a  well- 
marked  ptosis  is  found.  Apparently  the  food  is  not  promptly  for- 
warded by  the  descended  stomach  and  vague  discomfort  is  experienced 
l)y  the  individual,  which  restrains  him  from  eating  sufficiently,  as  that 
is  supposed  by  him  to  increase  his  distress.  Following  this  there  de- 
velops a  moderate  degree  of  anemia  and  inability  to  apply  oneself  dili- 
gently to  any  undertaking,  a  mental  as  well  as  a  physical  weakness  fol- 
lowing. There  is  still  some  question  as  to  the  relation  between  enterop- 
tosis  and  gastric  neurosis.  Some  would  attribute  all  the  dyspeptic  and 
nervous  symptoms  to  the  anatomical  change  in  the  position  of  the 
stomach,  but  others  have  advanced  excellent  proof  of  their  lack  of  asso- 
ciation in  the  following  points: 

1.  Those  who  suffer  from  this  condition,  as  they  pass  adult  life,  lose 
their  nervous  irritability  and  experience  no  further  difficulty  with  their 
digestion,  though  the  stomach  and  colon  remain  in  their  distorted  con- 
dition. 

2.  As  stated,  we  may  find  the  most  extreme  grade  of  acquired  en- 
teroptosis  without  a  digestive  symptom,  and  occasionally,  in  the  con- 
genital form  with  well-marked  displacement,  no  complaint  is  made  of 
indigestion. 

3.  At  autopsy  some  of  the  most  bizarre  anomalies  of  position  of  in- 
testine and  stomach  are  found  where  no  complaint  was  ever  made  dur- 
ing life,  and  in  pregnancy  it  is  well  known  that  all  the  digestive  organs 
must  assume  new  positions. 

4.  We  often  find  hypersecretion  associated  with  gastroptosis,  whose 
subjective  symptoms  can  be  overcome  by  treatment,  but  the  position 
of  the  stomach  remains  the  same  and  the  hydrochloric  acid  is  not 
lessened.  Neither  the  excess  of  hydrochloric  acid  nor  the  position  of 
the  stomach  caused  the  symptoms,  but  the  excessive  nervous  irritability 
of  the  patient.  We  can  only  theorize  in  explanation  by  saying  that 
persons  with  an  unstable  or  undeveloped  nervous  system,  which  causes 
the  gastric  neurosis,  also  have  an  unstable  and  undeveloped  muscular 
system,  which  causes  the  enteroptosis.  Still,  there  are  actual  patho- 
logical conditions  which  are  closely  associated  with  this  change  of 


ENTEROPTOSIS    (SPLANCHNOPTOSIS)  351 

position  of  the  digestive  tract.  Take,  for  instance,  the  kinking  of 
the  ureter  from  nephroptosis  (prolapse  of  the  kidney),  often  pro- 
ducing hydronephrosis;  the  acute  angle  of  the  splenic  flexure  of  the 
eolon,  whereby  in  the  radiogram  a  portion  of  the  transverse  and  the 
descending  part  seem  to  be  adherent,  producing  symptoms  of  stenosis ; 
the  twisting  of  the  horizontal  portion  of  the  duodenum,  producing 
symptoms  of  narrowed  pylorus,  accompanied  by  vomiting;  and  the 
frequent  association  of  jaundice  and  gallstones,  with  the  pull  pro- 
duced on  the  choledochus  by  the  prolapse  of  the  duodenum  or  liver. 

Inspection  of  the  abdomen  shows  a  peculiar  configuration.  The 
distance  between  the  xiphoid  and  the  navel  is  apparently  lengthened, 
the  waist  line  is  sunken,  the  epigastrium  is  concave  or  canoe-shape, 
and  there  is  bulging  at  the  navel.  This  is  the  condition  in  the  con- 
genital form ;  in  the  acquired,  when  the  patient  stands,  the  pendulous 
belly  is  easily  discerned.  The  diastasis  or  separation  of  the  recti,  with 
visible  peristalsis,  belongs  only  to  the  latter  form  where  women  have 
torne  children  rapidly.  Pulsations  of  the  aorta  are  also  plainly  vis- 
ible, and  in  a  young  person  it  is  rare  that  this  does  not  presage  a  gas- 
troptosis.  When  the  fingers  are  placed  over  this  pulsating  part,  pain 
is  often  experienced,  and  it  is  sometimes  difficult  to  differentiate  it 
from  the  tender  point  of  gastric  ulcer  until  it  is  found  that  the  stomach 
is  below  the  palpating  fingers.  When  one  compares  the  feeble  heart 
sounds  and  radial  pulse  with  this  powerful  action  of  the  abdominal 
aorta,  it  would  seem  that  some  local  influence  produced  it.  This  has 
been  ascribed  to  the  irritability  of  the  celiac  plexus,  incited  by  the 
pull  of  the  prolapsed  stomach  upon  it,  which,  at  the  same  time  causes 
the  pain.  To  particularize,  we  must  consider  each  organ  in  turn 
which  is  liable  to  be  displaced,  for  they  are  not  all  necessarily  ptosed 
at  the  same  time,  and,  even  if  they  are,  some  will  produce  symptoms 
and  some  will  not.  For  instance,  with  combined  gastroptosis  and 
coloptosis  we  may  have  eructations  and  heartburn  without  constipa- 
tion, or  vice  versa. 

GASTROPTOSIS. 

Gastroptosis  alone,  or  in  combination  with  other  ptoses,  is  prob- 
ably not  more  common,  but  more  easily  distinguishable,  since  the  out- 
line of  the  stomach  is  easily  made  out,  while  that  of  the  colon  is  much 
more  difficult,  and  for  its  position  we  must  rely  largely  on  the  x-ray 
examination.  Of  a  ptosis  of  the  whole  organ,  one  can  hardly  speak, 
for  the  cardia  is  fixed  and  only  the  pylorus  and  antrum  are  freely  mov- 
able, so  that  it  is  this  portion  which  changes  its  position  by  moving 


352 


DISEASES   OF   THE   DIGESTIVE   TRACT 


downward  and  to  the  left  until  the  whole  organ  often  assumes  a  verti- 
cal direction. 

By  radiogram  it  has  also  been  shown  that  the  course  of  the  food  is 
changed  in  gastroptosis  and  that  it  does  not  enter  the  fundus,  but 


Fig.  <i9.- 


-K-idiojfrani  of  stomach  in  congenital  gastroptosis.      Organ  lying  wholly  below  iliac 
cres.s,  with  patient  standing.      (Collection  of  Dr.  Arial  W.  George.) 


falls  directly  to  the  antrum,  thus  pushing  the  pylorus  still  further 
downward  and  increasing  the  distance  between  the  cardia  and  pylorus. 
This  stretching  takes  place  at  the  expense  of  the  muscular  structure^ 
so  that  the  organ  cannot  be  contracted  on  its  contents  and  soon  be- 


ENTEROPTOSIS    (SPLANCHNOPTOSIS)  353 

comes  atonic.     The  diagnosis  is  made  more  probable  by  the  presence 
of  marked  succussion  either  at  a  point  where  it  is  not  usually  found, 
below  the  navel,  or  at  a  time  when  not  customary — two  hours  after  a 
test  breakfast  or  five  hours  after  a  hearty  meal.     This  does  not  always 
indicate  atony,  but  that  the  stomach  has  slipped  from  its  position  be- 
neath the  costal  arches  and  is  lying  against  the  abdominal  wall.     Dis- 
tention with  the  effervescent  mixture  also  shows  the  lower  border  be- 
low the  navel,  and  the  upper  border  is  distinctly  seen,  a  thing  that 
never  happens  in  a  normal  stomach.     Sometimes  without   the   dis- 
tention of  gas,  if  the  patient  is  asked  to  press  downward,  the  lesser 
curvature   comes  into  view;  the   percussion   outline  of  the   inflated 
stomach  will  show  the  upper  border  at  or  below  the  costal  arch.     Un- 
fortunately the  inflated  stomach  often  assumes  bizarre  shapes,  which 
do  not  always  correspond  to  its  real  anatomical  relation,  so  that  we  fly 
to  x-ray  examinations,  which,  in  spite  of  scoffers,  rarely  lie.     When  the 
tonicity  of  the  stomach  is  maintained,  in  spite  of  its  changed  position, 
the  bismuth,  and  presumably  the  food,  does  not  take  longer  to  depart 
than  in  the  normal  stomach ;  in  fact,  some  declare  that  a  hypermotility 
exists.     Gastroptosis  is  always  associated  with  a  group  of  perverted 
sensations,  either  connected  with  nervous  dyspepsia,  such  as  gaseous 
eructations  of  the  noisy  kind,  veritable  fire-cracker  explosions  (which 
at  a  clinic  patients  are  only  too  anxious  to  exhibit  to  the  doctor), 
cardialgia  or  painful  lump  in  the  throat,  and  nausea  unaccompanied 
by  vomiting,  or  with  the  results  of  the  mechanical  change  of  the  posi- 
tion of  the  stomach.     Patients  complain  of  the  dragging  sensation  in 
their  abdomen  after  a  full  meal,  and  often  content  themselves,  among 
the  poorer  classes,  with  a  little  soup  or  rice  to  avoid  this.     Discomfort 
of  this  nature  can  also  be  allayed  by  lying  down.     Others  have  a  per- 
sistent backache  while  on  their  feet,  induced,  as  is  supposed,  by  the 
pull  of  the  filled  stomach  on  the  celiac  ganglion,  which  is  also  found 
tender,  while  patients  also  complain  of  the  throbbing  of  the  abdominal 
aorta  that  can  be  seen  pulsating.     It  is  rather  surprising  to  note  the 
number  of  women  in  an  out-patient  clinic,  the  mothers  of  eight  to 
fourteen  children,  as  they  tell  you,  who  complain  of  these  symptoms. 
It  is  also  difficult  to  always  exclude  gastric  ulcer,  but  those  with 
ptosis  feel  worse  w^hile  standing  than  when  lying  on  the  right  side, 
worse  after  a  large  meal  than  after  a  small  one,  though  it  be  liquid, 
while  the  tender  point  is  above  the  stomach,  all  of  which  is  the  reverse 
in  gastric  ulcer.     Sufferers  from  gastroptosis,  over  50  years  of  age  are 
always  apprehensive  of  cancer  and  a  reassurance  of  freedom  from  it 
aids  greatly  in  dissipating  symptoms. 


354 


DISEASES   OF    THE   DIGESTIVE   TRACT 


COLOPTOSIS. 

Coloptosis  plays  a  much  less  important  part  than  the  ptosis  of  the 
stomach,  but,  still,  has  its  evils  on  account  of  the  persistent  constipa- 


Fig.  70. — Radiogram  of  W-shaped  colon. 


tion  that  accompanies  it.     There  may  be  a  prolapse  of  either  the 
hepatic  or  splenic  flexure,  usually  the  former,  or,  what  is  more  com- 


ENTEROPTOSIS    (SPLANCHNOPTOSIS)  355 

mon,  of  the  transverse,  by  which  the  V-shape  or  W-shape  is  assumed^ 
causing  stasis.  Curshman  has  called  attention  to  the  vagaries  in  the 
position  of  the  sigmoid,  changes  due  either  to  congenital  malforma- 
tions in  the  mesentery  or  local  peritonitic  processes,  which  must  al- 
ways be  differentiated  from  simple  asthenic  sinking  of  the  colon.  The 
diagnosis  of  coloptosis  can  usually  be  made  by  inflation  of  the  colon 
through  the  rectum,  either  by  air  or  water,  when  percussion  will  give 
its  outline,  though,  of  course,  with  some  artificial  changes  not  justified 
by  the  actual  anatomical  position;  or,  what  is  much  better,  by  radio- 
gram or  an  examination  with  the  fluoroscope,  by  which  also  the  ques- 
tion of  adhesions  can  usually  be  settled. 

Symptoms. — The  symptoms  of  coloptosis  are  not  usually  severe,  un- 
less, as  sometimes  happens,  a  local  peritonitic  inflammation  takes  places 
accompanied  by  adhesions,  when  symptoms  of  real  stenosis  may  be 
found,  demanding  in  one  case,  in  which  our  interest  was  aroused,  an  an- 
astomosis of  the  cecum  with  the  sigmoid.  That  a  simple  ptosis  may 
cause  a  stenosis  is  out  of  the  question;  the  feces  move  more  slowly 
through  the  distorted  canal,  but  move  they  do.  Another  unpleasant 
result  of  the  prolapsed  colon  is  the  spasmodic  contraction  of  certain 
sections,  which  can  be  felt  as  a  round  cord  or  sausage-like  body,  the 
"corde  colique"  of  Glenard.  AVhether  they  ever  relax  is  difficult  to 
say,  for  at  subsequent  examinations  of  the  patient  they  are  found  at 
the  same  place.  The  favorite  site  is  the  sigmoid,  less  common  the 
descending  and  transverse  colon,  and  almost  never  the  ascending  and 
cecum.  This  spasmodic  contraction,  contrary  to  general  belief,  has 
nothing  to  do  with  constipation,  the  fecal  matter  passing  through  this 
part  of  the  tract  readily.  Mucus  in  the  stool  is,  in  our  opinion,  a  fre- 
quent concomitant  of  this  condition,  but  whether  a  causative  relation 
exists  between  them  is  not  certain.  It  does  produce,  however,  the 
most  dolorous  sensations  in  the  patients,  mostly  neurotic  men  and 
women,  described  as  a  constant  pain,  never  leaving  except  in  sleep,  a 
feeling  of  heat  on  one  side  (where  the  cord  could  be  felt)  and  cold  on 
the  other,  a  feeling  as  if  all  motion  of  the  gas  in  the  intestine  stopped 
at  this  point  (transverse  colon  just  beyond  the  hepatic  flexure).  The 
latter  two  were  x-rayed,  a  marked  V-shaped  loop  being  found  in  one 
and  an  apparent  adhesion  between  the  ascending  and  transverse  colon 
in  the  other,  with  complete  relief  in  the  one  by  operation  (separation 
of  adhesions)  and  absolutely  no  change  in  the  sensation  of  the  other 
(suspension  of  the  colon). 

The  cecum  mobile  also  belongs  to  coloptosis.  In  the  right  iliac 
region  we  find  a  tympanitic  area  where  suceussion  may  be  easily 


356  DISEASES   OF   THE   DIGESTIVE   TRACT 

elicited,  with  some  tenderness  and  frequent  complaint  on  the  part  of 
the  patient  of  occasional  evanescent  attacks  of  pain,  which  often 
arouses  suspicion  of  chronic  appendicitis.  Lordennais  gives  a 
pathognomonic  sign  of  this  condition,  which  consists  of  elicitation  of 
pain  when  the  fecal  contents  are  forced  from  the  transverse  and 
ascending  colon  into  the  cecum  by  massage,  but  none  when  the  con- 
tents of  the  cecum  are  pushed  into  the  ascending  colon ;  pressure  di- 
rectly over  the  cecum  relieves  the  pain,  but  it  returns  when  the  hand 
is  removed.  Constipation  usually  accompanies  this  atony  of  the 
cecum,  and  the  radiogram  usually  shows  that  this  portion  of  the  colon 
is  very  much  prolapsed ;  in  fact,  in  one  case  under  our  observation 
almost  reaching  the  rectum.  Operation  showed  no  pathologic  changes 
of  the  appendix,  but  there  were  adhesions  which  held  the  cecum  in  its 
distorted  position,  evidently  starting  from  that  appendage.  On  ac- 
count of  the  stagnation  of  fecal  contents  in  the  cecum,  a  chronic  colitis 
is  started  up  at  this  point,  with  tenderness  and  a  dragging  sensation 
j\Iany  physicians  reject  operation  as  useless,  and  rely  on  diet,  massage, 
etc.,  but  in  a  few  cases  under  our  observation,  some  of  which  had  been 
treated  medicinally  for  long  periods  (the  one  mentioned  above  for 
five  years),  freeing  the  adhesions  has  given  relief  from  pain  and 
checked  the  constipation.  When  constipation  is  a  prominent  symptom 
of  coloptosis,  it  is  apparently  not  due  to  the  mechanical  distortion  of 
the  intestine,  but  to  nervous  influences,  for,  when  the  colon  has  been 
properly  suspended,  the  restricted  defecation  still  continues.  As  a 
further  proof  of  the  lack  of  causative  influence  on  the  constipation 
by  the  abnormal  position  of  the  colon,  we  may  observe  that  diarrhea 
exists  as  often  as  the  opposite  condition.  Zweig  regards  both  states 
as  not  connected  with  the  malposition,  but  associated  neuroses — one 
a  state  of  depression  and  the  other  one  of  excitation. 

NEPHROPTOSIS. 

Nephroptosis,  or  prolapse  of  the  kidney,  was  formerly  regarded  of 
great  import  before  our  knowledge  of  nephroptosis  was  enlarged  to 
include  all  the  abdominal  organs  liable  to  ptosis.  While  the  kidney 
alone  may  be  prolapsed,  as  a  general  rule  it  is  merely  a  symptom  of 
universal  ptosis,  whether  congenital  or  acquired.  The  cause  is,  pri- 
marily, weakness  of  the  muscular  structure  of  the  abdominal  walls, 
and,  secondarily,  the  presence  of  prolapse  of  the  right  colic  flexure, 
pressure  of  the  liver,  unduly  long  renal  vessels  and  ligaments,  gas- 
trectasis,  rapid  childbearing,  and  the  use  of  ill-fitting  corsets.     Hence 


ENTEROPTOSIS    (SPLANCHNOPTOSIS)  357 

it  is  largely  restricted  to  women,  though  men  are  sometimes  sufferers 
from  it.  Formerly  there  was  a  glut  of  kidney  suspension  and  fixation, 
but,  as  very  little  relief  was  ever  obtained,  because  the  kidney  was 
only  one  of  the  various  organs  which  had  undergone  ptosis,  at  present 
but  little  is  heard  of  this  operation.  Its  frequency  is  much  more 
common  than  suspected  when  a  search  is  made.  In  an  out-patient 
clinic,  under  our  supervision,  much  frequented  by  women  who  have 
borne  many  children,  the  records  showed  that  at  least  in  one  of  every 
ten  cases  a  note  was  made  of  prolapsed  right  kidney,  with  the  lower 
pole  at  the  navel  and  sometimes  even  below ;  so  common  is  it,  in  fact, 
that  no  attention  is  paid  to  it,  except  when  the  patient  complains  of 
frequent  micturition  with  an  absolutely  clear  urine.  A  left-sided 
nephroptosis  is  much  more  uncommon,  although  Albu  in  3400  patients 
in  his  polyclinic  found  it  in  4  per  cent  of  the  males  and  11  per  cent 
of  the  females.  It  cannot  be  as  frequent  in  the  United  States,  or  else 
we  are  not  as  skillful  in  detecting  it.  The  detection  of  the  prolapsed 
right  kidney  by  bimanual  manipulation  is  not  difficult.  The  patient 
lies  on  the  left  side,  while  the  examiner,  placing  his  left  hand  against 
the  lumbar  region  behind,  makes  opposing  pressure  with  the  finger  tips 
of  the  right  hand  under  the  right  costal  border,  and  asks  the 
patient  to  breathe  deeply,  by  which  means  four  degrees  of  dislocation 
can  be  determined : 

1.  The  kidney  shows  itself  movable  by  respiration — a  normal  con- 
dition according  to  J.  Israel. 

2.  The  kidney  shows  a  dislocation  of  the  first  grade — that  is,  one- 
third  to  two-thirds  of  it  can  be  felt. 

3.  The  kidney  shows  a  dislocation  of  the  second  grade — that  is, 
allows  itself  to  be  moved  freely  by  the  palpating  fingers  and  moves 
with  every  excursion  of  the  diaphragm. 

4.  The  kidney  is  displaced  and  fixed  by  adhesions — in  other  words, 
has  assumed  a  new  position  and  is  firmly  fixed  there.  Only  disloca- 
tions of  the  first  and  second  grades  are  congenital,  and,  when  the 
kidney  is  firmly  fixed  by  peritoneal  inflammation,  the  displacement  is 
caused  by  some  mechanical  means. 

Symptoms. — The  symptoms  of  nephroptosis  are  rarely  character- 
istic, and  are  more  often  due  to  the  nervous  irritability  accompanying 
it.  The  women,  who  are  the  chief  sufferers,  complain  of  fullness  and 
a  dragging  sensation  in  the  upper  right  half  of  their  abdomen  and 
often  of  a  pain  in  the  sacral  or  lumber  region.  All  these  symptoms 
are  less  burdensome  or  disappear  when  the  patient  lies  down,  and  are 
much  exaggerated  when  she  is  on  her  feet  all  the  day.     Very  rarely 


358  DISEASES   OF    THE   DIGESTIVE   TRACT 

does  a  kink  in  the  ureter  occur  sufficient  to  cause  a  hydronephrosis, 
and  then  only  when  associated  with  an  abnormal  blood  vessel.  In  a 
clinic  where  hundreds  of  these  women  pass  through  monthly  it  is  rare 
to  find  more  than  a  complaint  of  an  irritable  bladder,  with  frequent 
micturition,  dependent  on  this  prolapse.  The  urine  is,  in  our  expe- 
rience, invariably  clear  and  contains  no  albumin,  though  Winternitz 
declares  intermittent  albuminuria  not  uncommon.  The  outcome  of  all 
forms  of  these  ptoses  appears  to  indicate  that,  once  a  possessor  of  a 
prolapsed  kidney  or  stomach,  always  a  possessor,  unless  by  a  fortunate 
surgical  operation  the  ptosed  organ  can  be  stitched  in  its  proper  posi- 
tion and  made  to  remain  there,  w^hich,  on  account  of  the  relaxed  condi- 
tion of  all  tissues,  is  difficult.  That  the  time  often  comes  when  patients 
complain  no  longer  of  symptoms  is  true,  but  the  kidney  has  not  as- 
cended to  its  proper  site — at  best,  has  become  fixed  in  its  new  position, 
so  that  it  no  longer  "wanders" — nor  has  the  stomach  made  its  way 
back  to  its  home  under  the  costal  arches.  At  the  most,  the  patient  has 
put  on  fat,  so  that  the  malpositions  can  no  longer  be  detected  by  palpa- 
tion, or,  what  is  better,  the  patient  has  lost  his  nervous  irritability 
without  replacement  of  his  organs.  This  is  not  uncommon  after  50 
years  of  age,  and  a  "cure"  of  this  kind  in  a  minister  who  had  suf- 
fered all  his  life  from  nervous  dyspepsia,  and  carried  his  stomach 
largely  in  the  left  lower  quadrant  of  his  abdomen,  brought  us  no  little 
local  renown.  Anyone  who  imagines  that,  by  the  suspension  of  a 
kidney  or  stomach,  his  patient  is  immediately  cured  will  meet  with 
many  disappointments,  and  will  soon  learn  that  he  advises  a  suspen- 
sion in  the  same  way  that  he  writes  a  prescription — with  no  positive 
assurance  that  either  will  produce  a  cure.  After  the  suspension,  how- 
ever, hygiene  and  roborant  measures  are  vastly  more  effective  than 
before,  but  must  be  continued  for  a  long  period  before  the  normal  tone 
is  restored.  The  length  of  life  is  not  shortened  one  iota  by  the  pres- 
ence of  enteroptosis,  nor  can  anything  in  our  experience,  be  found  t« 
assure  one  that  the  victims  of  this  condition  are  any  more  liable  to 
pulmonary  tuberculosis,  pernicious  anemia,  etc.,  than  any  others, 
though  they  often  succumb  to  it  as  do  others.  Furthermore,  they  are 
surely  much  more  free,  if  not  entirely  so,  from  degenerative  diseases 
of  the  heart  and  blood  vessels,  such  as  cardiac  dropsy,  apoplexy, 
arteriosclerosis,  and  angina  pectoris.  Stiller  would  have  us  believe, 
also,  that  the  possessor  of  prolapsed  abdominal  organs  is  much  less 
liable  to  rheumatism,  diabetes,  and  chronic  renal  diseases.  Osier  may 
well  say,  "Blessed  be  he  who  after  60  has  albumen  in  his  urine,"  evi- 
dently meaning  that,  when  conscious  of  it,  the  patient  takes  better  care 


ENTEROPTOSIS    (SPLANCHNOPTOSIS)  359 

of  himself,  but  it  is  difficult  to  persuade  patients  that  with  enteroptosis 
they  are  to  be  envied  of  their  neighbors  because  less  prone  to  these 
other  ailments. 

TREATMENT. 

The  treatment  of  enteroptosis  is  regarded  by  all  as  still  a  faulty  one, 
since  no  means  has  yet  been  devised  to  raise  with  certainty  the  pro- 
lapsed organs  to  their  former  position  outside  of  direct  suspension  by 
a  surgical  operation,  and  even  then,  unfortunately,  in  many  cases  they 
do  not  remain  permanently  where  placed.  But  associated  with  these 
displacements,  as  stated,  there  is  always  an  unbalanced  nervous  sys- 
tem, and  here  prophylaxis  plays  a  prominent  part  in  avoiding  and  de- 
laying as  far  as  possible  what  the  family  physician  can  readily  see  lies 
in  store  for  those  children  with  these  anomalies.  The  school  physician 
should  also  be  warned  that  those  whom  he  can  readily  recognize  as  of 
the  Stiller  type  should  be  spared  as  far  as  possible,  particularly  at 
puberty,  the  undue  mental  strain  brought  on  by  prizes  and  other  in- 
citements to  greater  mental  effort,  by  which  often  a  long  period  of 
nervous  dyspepsia  and  its  discomforts  may  be  avoided.  One  hears 
so  often  of  students  ''breaking  down"  under  their  studies,  but  it  is 
usually  those  with  their  stomach  in  the  wrong  position.  These  youths 
should  be  carefully  instructed  as  to  diet  by  urging  them  to  indulge 
in  milk,  cheese,  eggs,  fruits,  and  vegetables,  rather  than  meats,  for 
many  of  them  are  truly  carnivorous  animals  in  their  habits.  The 
asthenic  chlorotic  girl,  with  stomach  below  the  belt  line,  does  not  need, 
so  much,  rare  beef  and  Bland's  pills  as  she  does  cheese,  butter,  and 
tennis.  Athletics  should  be  indulged  in  to  moderation,  for  it  is  im- 
possible by  their  means  to  make  a  brawny  man  out  of  a  narrow-chested 
stripling  of  a  school  boy,  and  often  the  latter,  in  his  efforts  to  equal 
his  neighbor  in  acts  of  prowess,  does  himself  actual  harm.  All  these 
precautions  are  taken,  not  to  correct  a  malposition,  but  to  stave  off 
its  concomitant,  gastric  neurosis,  which,  if  deferred  by  hygienic  means 
beyond  the  age  of  puberty,  may  never  make  its  malign  appearance. 
The  real  therapy  of  enteroptosis  aims  to  accomplish  two  purposes — 
first,  by  mechanical  means  to  prevent  the  further  descent  of  the  dis- 
placed abdominal  organs,  and,  second,  by  various  forms  of  treatment 
to  check  the  multitudinous  symptoms  of  gastric  neurosis  which  ac- 
company this  condition.  The  first  purpose  is  accomplished  partially 
by  the  various  abdominal  bands,  originally  recommended  by  Glenard, 
and,  as  human  ingenuity  has  a  wide  field  here,  the  number  of  recom- 
mended supports  is  legion.     But  right  here  we  must  bear  in  mind  that 


360 


DISEASES   OF   THE   DIGESTIVE   TRACT 


it  is  usually  only  the  acquired  form  that  can  be  benefited  by  a  binder, 
because  in  this  case  there  is  more  or  less  protrusion  of  the  abdomen,  the 
German  ' '  Hangebaueh, ' '  while  the  victim  of  the  congenital  form  often 
has  a  flattened  or  even  concave  abdomen,  with  absolutely  no  part  at 
which  the  counter  pressure  of  a  band  can  be  applied.  For  the  former 
class  we  recommend  bands  of  linen,  cotton,  or  silk,  with  or  without 
whalebone  supports,  and,  if  one  can  judge  from  the  expression  of  re- 
lief by  those  who  have  dragged  about  with  a  steadily  increasing  pull 


Fig.  71. — Storm  binder  for  gast^optosi^ 

from  their  ptosed  organs,  the  use  is  justifiable,  even  if  we  do  only 
replace  the  lost  resiliency  of  the  weakened  abdominal  walls  and  do 
not  raise  the  displaced  organs  an  atom.  Our  custom  is  to  determine 
the  lower  border  of  the  stomach  by  percussion  and  order  a  pad  placed 
below  this  line,  stitched  to  a  band,  w^hich  furnishes  added  comfort,  or, 
if  the  right  kidney  is  down,  the  pad  can  be  placed  just  below  the  lower 
border  of  this  organ  when  the  patient  is  h'ing  and  in  full  inspiration, 
although  all  must  be  somewhat  skeptical  about  holding  up  a  kidney. 
This,  of  course,  requires  that  every  band  be  made  to  measure,  for,  of 


ENTEROPTOSIS    ( SPLANCHNOPTOSIS^ 


361 


all  abominations,  the  readymade  abdominal  belt  is  the  worst.  To  pre- 
vent the  belts  from  rising,  straps  of  cotton  or  small  rubber  tubes  must 
pass  between  the  thighs,  and  in  fat  women  particular  care  must  be 
taken  that  talcum  powder  be  used  freely,  for  the  chafing  in  hot 
weather  may  set  up  a  sharp  vulvitis  in  women.  Often  they  prove  so 
annoying  that  they  are  given  up  by  patients,  and  many  have  attempted 
to  hold  the  belts  down  by  fastening  them  to  the  stockings.  These  do 
not  need  to  be  worn  at  night,  and  some  insist  that  when  put  on  before 


Fig.  72. — Application  of  plaster  according  to 
the  Rose  method,  rear  view. 


Fig.  73. — Application  of  plaster  according  to 
the  Rose  method,  front  view. 


rising,  they  should  hold  the  abdomen  with  the  same  contour  it  had 
before  assuming  an  erect  position,  a  test  few  of  them  will  stand. 

Not  all  patients  find  relief  in  the  belts,  so  that  in  the  clinic  it  is 
always  customary  to  apply  the  plaster  bandage  of  Rose  for  a  couple 
of  weeks  to  learn  whether  support  of  the  abdomen  will  relieve  the 
discomfort,  which,  if  successful,  is  followed  by  the  recommendation 
of  a  band.  The  end  of  a  good  2-inch  adhesive  zinc  plaster  is  attached 
to  the  skin  of  the  back  next  to  the  vertebral  column  and  brought  diag- 


362  DISEASES   OF   THE   DIGESTIVE   TRACT 

onally  around  the  left  side  of  the  chest  and  abdomen,  drawing  or  push- 
ing up  on  the  latter  to  the  right  Poupart's  ligament,  just  inside  of 
which  it  is  cut  off;  now,  beginning  at  the  same  point  in  the  back, 
bring  another  strip  around  the  right  side,  so  that  its  end  shall  lie  just 
within  the  left  Poupart's  ligament;  then  apply  the  third  piece  hori- 
zontally, with  its  center  below  the  lower  border  of  the  stomach  in  the 
median  line,  and  extend  the  two  ends  upward  and  backward,  drawing 
up  as  much  as  possible  on  the  pendulous  abdomen  until  the  ends 
meet  in  the  back.  No  portion  of  the  plaster  should  touch  the  crest  of 
the  ileum. 

This  plaster  support  can  be  worn  for  a  fortnight,  when,  if  it  does 
not  come  off  readily,  it  can  be  easily  removed  with  the  aid  of  a  little 
ether.     It  is  rare  that  any  irritation  of  the  skin  occurs,  but,  as  a  pre- 


Fig.  74. — Enriquez  air  cushion,  with  bulb  for  inflation. 

ventive,  the  patient  is  advised  to  rub  in  talcum  powder  after  it  is  ap- 
plied. Rarely,  on  account  of  itching,  it  is  necessary  to  remove  the 
plaster  and  allow  the  patient  to  go  without  it  for  a  few  days,  when 
it  may  be  reapplied.  When,  as  usually  occurs,  relief  is  obtained  from 
its  use  during  the  first  period,  an  abdominal  band  may  be  ordered,  or, 
in  a  clinic,  where  the  cost  is  often  prohibitive,  the  use  of  the  plaster 
may  be  continued.  Patients  usually  declare  that  the  dragging  sensa- 
tion disappears  immediately  after  its  application,  and  the  radiogram 
shows  that  the  stomach  is  raised  at  least  4  cm.,  which  probably  accounts 
for  the  relief.  The  operative  treatment  and  its  results  have  been  dis- 
cussed. Before  leaving  the  subject,  however,  mention  must  be  made 
of  the  Enriquez  pelotte,  or  an  air  cushion,  which  has  been  used  by  us 
with  some  success  for  the  congenital  cases  which  are  not  benefited  by 


ENTEROPTOSIS    (SPLANCHNOPTOSIS) 


363 


Fig.  75. — Kadiogram  oi  -in::.  1 
of  Enriquez  air  cusliion. 


Fig.    76. — Radiogram   of   stomach   after   six 
months'  use  of  Enriquez  air  cushion. 


Fig.  77. — Radiogram  of  colon  before  use  of 
Enriquez  air  cushion. 


Fig.  78. — Radiogram  of  colon  after  use  of 
Enriquez  air  cushion. 


364  DISEASES   OF   THE   DIGESTIVE   TRACT 

the  usual  form  of  binder.  The  former  consists  of  a  collapsible  air 
cushion,  which  is  inserted  next  the  skin  under  an  ordinary  abdominal 
band,  which  must  be  well  fortified  by  whalebone  to  prevent  its  stretch- 
ing. The  collapsible  bag  is  placed  just  below  the  lower  border  of  the 
stomach  and  then  inflated  with  an  air  bulb  to  the  point  of  comfort. 

Some  of  the  results  reported  by  Borgbjaerg  and  Fisher,  as  demon- 
strated by  radiogram  both  on  the  stomach  and  colon  after  six  months' 
use,  are  admirable.  The  lower  border  of  the  stomach  was  raised  at 
least  6  cm.,  even  when  before  its  use  the  same  w^as  6  cm.  below  the  level 
of  the  iliac  crest,  while  at  the  same  time  the  average  gastric  contents 
withdrawn  before  its  use,  six  hours  after  a  test  meal,  gave  an  average 
of  56  c.c,  but  after  a  month's  use  this  diminished  to  8  c.c.  The  colon 
followed  the  stomach,  being  raised  from  7  to  8  cm. 


CHAPTER  XIV 

NERVOUS  DYSPEPSIA  (GASTRIC  NEUROSIS.) 

In  the  use  of  these  terms  we  concede  at  once  that  the  nervous  dis- 
turbance is  general,  with  particular  prominence  placed  on  the  digestive 
disorder  either  by  the  physician  or  much  more  often  by  the  patient, 
or,  what  is  still  more  curious,  the  patient  has  a  new  complaint  at  each 
visit  to  the  clinic  or  doctor,  which  he  emphasizes — now  it  is  a  burning 
sensation  in  the  epigastrium,  now  an  ache  in  the  back  of  the  neck,  now 
insomnia,  so  that  it  is  always  a  question  whether  we  are  dealing  with 
a  neurasthenic  or  a  victim  of  functional  gastric  disease.  This  is  not 
to  imply  that  there  is  no  pathology  to  gastric  neurosis,  because,  in  the 
three  functions  of  secretion,  motility,  and  change  in  sensation  the  pa- 
tient is  far  removed  from  the  normal  individual  in  either  one  or  more. 
Another  thing  which  usually  marks  the  possessor  of  a  functional 
digestive  disorder  is  the  excellent  state  of  nutrition.  In  spite  of  a 
tale  of  suffering  which  would  convince  one  that  he  w^as  in  the  last 
stages  of  dissolution,  the  color  is  usually  good,  though  the  patient  may 
be  pale,  and,  if  persistent  abstinence  from  food  is  indulged  in  for  fear 
of  distress  after  eating,  moderate  emaciation  may  be  present.  In 
probably  no  other  line  of  diagnosis  have  modern  laboratory  methods 
been  of  such  aid  to  the  physician  as  in  disentangling  that  vague  group 
of  symptoms  known  to  Leube  as  nervous  dyspepsia.  Now  we  easily 
distinguish  a  group  of  secretory,  motility,  and  sensation  disturbances 
of  nervous  origin,  which  may  be  classified  as  follows : 

1.  Distiiriances  of  Secretion. 

a.  Increase. 

Intermittent,  "I 

Digestive.  I  Superacidity. 

Continuous.  I 

b.  Diminution. 

Partial  suppression — Subacidity. 
Complete  suppression — Achylia  gastrica. 
365 


366  DISEASES   OF   THE   DIGESTIVE   TRACT 

2.  Disturhances  of  Motility. 

a.  Increase. 

Cardiospasm, 
Pylorospasm. 
Nervous  eructation. 
Vomiting. 

b.  Diminution. 

Hypotony  (gastric  myasthenia). 

Insufficiency  of  the  cardia  (rumination,  regurgitation,  etc.). 

3.  Disturhances  of  Sensation. 

Bulimia  (ox  hunger). 
Disgust  for  food. 
Nausea. 
Cardialgia. 

SECRETORY  NEUROSES. 

a.  Hypersecretion. — One  must  begin  by  acknowledging  that  this 
is  only  too  often  associated  with  chronic  gastroduodenal  ulcer,  as  the 
Mayos  insist.  Still,  we  have  so  many  instances  where  at  least  all  our 
frail  efforts  to  detect  an  ulcer  are  in  vain,  and  where,  unless  more 
light  is  shed  on  the  question,  we  must  continue  to  regard  them  of 
neurotic  origin.  ]\Iuch  oftener,  however,  we  have  the  combination  of 
delayed  motility  and  hypersecretion,  due,  as  is  supposed,  to  the  longer 
stay  of  food  in  the  stomach.  It  nevertheless  seems  to  us  that  those 
who  attempt  to  prove  that  the  stomach  can  secrete  a  gastric  juice  of 
varying  hydrochloric  acid  content  have  failed,  and  to  us,  at  least,  an 
increase  in  the  percentage  of  this  acid  means  an  increased  secretion 
of  the  digestive  fluid,  with  no  greater  change  in  composition  than  one 
would  expect  to  find  in  the  saliva  when  there  is  so-called  salivation. 
There  is  probably  no  condition  more  common  among  this  whole  group 
of  neuroses,  and  without  the  laboratory  no  one  can  tell  whether  hyper- 
secretion or  fermentation  is  the  cause  of  the  heartburn  of  which  pa- 
tients complain. 

Symptoms. — The  chief  symptom,  apart  from  the  heartburn,  or 
pyrosis,  which  is  often  located  under  the  sternum,  or  among  the  more 
ignorant  in  the  "heart,"  are  eructations  of  sour-tasting  fluid,  begin- 
ning, some  say,  directly  after  eating,  some  later  (one  to  two  hours), 
and  particularly  after  fatty  or  very  highly  spiced  or  salted  articles  are 
eaten.     This  symptom,  as  well  as  the  burning,  can  be  relieved  by  any 


NERVOUS   DYSPEPSIA    (GASTRIC    NEUROSIS)  367 

albuminous  food,  like  milk  or  egg,  or  the  old  reliable  cooking  soda. 
The  appetite  remains  excellent,  or  bulimia  (ox  hunger)  often  exists, 
nutrition  is  unimpaired;  in  fact,  this  condition  is  often  found  in  the 
obese.  When  hunger  cannot  be  at  once  gratified,  patients  begin  to 
tremble,  are  extremely  irritable,  and  are  frequently  in  a  fainting  con- 
dition. The  stool  is  usually  scanty,  and  may  occur  every  two  to  three 
days,  which  undoubtedly  acts  reflexly  in  keeping  up  the  hypersecre- 
tion. Actual  pain  is  rarely  present,  and,  when  it  is  well  substantiated, 
should  arouse  the  physician's  suspicion  that  the  condition  is  no 
longer  a  functional  neurotic  affair,  but  that  actual  gastroduodenal 
ulcer  exists.  Such  pain  comes  on  at  3  or  -4  o'clock  in  the  morning, 
but  is  not  the  typical  ' '  hunger  pain ' '  of  ^lonyhan,  since  it  is  not  per- 
sistent. As  there  is  no  measure  for  pain,  it  is  often  difficult  to  ob- 
tain from  ignorant  patients  the  degree  of  suffering,  for  it  is  cus- 
tomary for  them  to  regard  all  discomfort  as  a  manifestation  of  pain. 
The  best  proof,  however,  of  the  presence  of  hypersecretion  is  the  ex- 
istence of  acidities  exceeding  the  normal  limits,  which  are  usually 
given  for  an  hour  after  the  bread  and  water  breakfast  as  30-40  and 
50-60.  When  these  figures  are  exceeded,  and  the  difference  in  the  acid- 
ities is  less  than  20 ;  when  the  residue  by  centrif uging  is  less  than  one- 
fifth  of  the  total  volume  and  the  amount  of  hydrochloric  acid  in  both 
the  gastric  contents,  originally  withdrawn,  and  the  residue  obtained 
from  the  wash  water  exceeds  80,  then  we  may  be  assured  that  we  are 
dealing  with  a  digestive  hypersecretion,  and,  if  occult  hemorrhage 
is  lacking,  that  it  is  probably  of  nervous  origin.  When  the  fasting 
wash  water  contains  hydrochloric  acid  freely  without  food  fragments, 
we  may  regard  this  as  continuous;  and  when  this  condition  is  only 
found  at  intervals,  we  may  call  it  intermittent.  ]\lany  patients  have 
periodic  attacks  of  hypersecretion,  often  accompanied  by  headache 
and  vomiting,  while  in  the  quiescent  periods  they  feel  perfectly  well. 
Seasickness,  too,  has  been  proven  to  be  accompanied  by  hypersecre- 
tion. We  must  not,  however,  stick  too  strictly  to  our  acid  figures,  for 
many,  as  stated,  will  suffer  from  subjective  symptoms  when  the  acid 
factors  are  under  the  limits  given  and  others  will  experience  no  dis- 
comfort when  they  are  far  above  it.  The  former,  apparently,  have  a 
typical  acid  hyperesthesia,  as  Talma  calls  it.  The  intermittent  form 
may  also  be  associated  with  tabes,  existing  in  the  manifestations  of 
the  so-called  gastric  crises. 

Treatment. — The  treatment,  no  matter  how  energetic  or  of  what 
character,  does  not  diminish  to  any  great  extent  the  hypersecretion, 
except  possibly,  as  has  occurred  often  in  our  experience,  to  change  the 


368  DISEASES   OF   THE   DIGESTIVE   TRACT 

continuous  to  the  digestive  form,  thereby  relieving  the  discomfort 
when  the  stomach  is  empty.  The  most  one  can  hope  to  do  is  to  render 
the  mucous  membrane  less  sensitive  to  these  high  acidities,  for  the 
organ  persists  in  its  exaggerated  secretion.  Here  we  reach  the  dis- 
puted question  as  to  whether  protein  or  amylaceous  food  is  most  fitted 
to  diminish  secretion.  All  physiologic  tests  on  animals  and  normal 
humans  are  of  little  avail ;  the  results  derived  cannot  be  transferred  to 
the  overexcitable  glands  of  a  hypersecretion.  The  only  tangible  way 
to  settle  this  question  is  its  application  to  those  suffering  from  hyper- 
secretion, and  this  has  been  done  by  Soerensen  and  ^letzger,  who  em- 
ployed a  mixed  diet,  exclusive  protein,  and  carbohydrate  meals,  with 
the  result  that  practically  no  difference  could  be  discovered  in  the 
amount  of  hydrochloric  acid  secreted.  We  are  apparently  between 
Scylla  and  Charybdis  when  we  attempt  to  decide  according  to  the  older 
views,  which  are,  that  protein  neutralizes  acid,  but  excites  a  greater  se- 
cretion, while  amylaceous  food  excites  less  secretion,  but  is  badly  di- 
gested by  ptyalin  in  the  stomach.  In  spite  of  scientific  views  to  the 
contrary,  it  has  always  seemed  to  us  that  mechanical  influences  played 
a  great  part  in  the  incitement  of  the  gastric  glands  to  activity;  the 
coarser  the  food  taken,  whether  protein  or  amylaceous,  the  greater 
the  secretion,  and  vice  versa.  Still,  Bickel  has  performed  a  great  serv- 
ice in  determining  by  experiment  those  articles  of  food  and  drink 
which  are  mild  or  strong  excitors  of  gastric  secretion,  and  his  table  is 
as  follows: 

MILD   EXCITORS   OF    SECRETION. 

1.  Drinks. — "Water,  alkaline  waters,  tea,  cocoa  (containing  fat), 
cream,  and  white  of  egg. 

2.  Condiments. — 0.9  per  cent  salt  solution. 

3.  Solid  foods. — Boiled  meat,  fats  of  all  kinds,  all  boiled  vegetables, 
potatoes,  cabbage,  asparagus,  red  cabbage,  cauliiSower,  spinach,  and 
white  turnip,  all  in  puree  form. 

STRONG   EXCITORS   OF    SECRETION. 

1.  Drinks. — All  alcoholic  and  carbon  dioxide-containing  beverages, 
coffee,  fat-free  cocoa,  skimmed  milk,  bouillon,  beef  extracts,  egg  yolk, 
and  hard  boiled  eggs. 

2.  Condiments. — Mustard,  nutmeg,  pepper,  paprika,  and  salt  in 
greater  than  0.9  per  cent  concentration. 

3.  Solid  foods. — Rare  roast  meat,  dark  meats,  smoked  and  salted 
meats,  black  and  rye  bread  (brown  bread). 


NERVOUS  DYSPEPSIA    (GASTRIC   NEUROSIS)  369 

It  is  apparent  that,  as  to  diet,  we  must  decide  which  we  shall  re- 
gard as  paramount — the  total  acidity  or  the  free  hydrochloric  acid. 
The  former  is  undoubtedly  lessened  by  the  use  of  a  largely  vegetarian 
diet,  but  it  is  not  the  mixture  of  acid  phosphates,  Avhich  are  neces- 
sarily increased  by  the  excessive  use  of  meat,  and  acid  albumen,  which 
cause  no  distress,  but  the  free  hydrochloric  acid  which  produces  the 
burning,  as  is  proven  by  the  fact  that  an  attack  of  pyrosis  can  be 
allayed  temporarily  by  white  of  egg,  milk,  or  an  alkali.  Hence  it 
would  seem  necessary  to  make  protein  a  large  factor  in  the  diet  in  this 
condition,  but  it  may  be  in  the  form  of  those  articles  of  food  which 
contain  it  other  than  meat.  Furthermore,  since  it  has  never  been 
proven  that  proteins  increase  the  free  hydrochloric  acid  beyond  the 
period  during  which  it  is  being  digested,  there  is  no  reason  to  strike 
them  from  this  dietar^^  Yon  Noorden  has  found  that  a  diet  contain- 
ing an  increased  caloric  value,  without  particular  reference  to  the 
percentage  of  protein  and  carbohydrates,  has  worked  best  with  the 
hypersecretors,  and  that  on  a  purely  vegetable  diet  the  patient  does 
not  gain  this  increased  nutrition,  and,  if  associated  with  general  nerv- 
ous disturbances,  his  disorder  becomes  worse  rather  than  better.  In 
the  obese  hypersecretors,  however,  it  cannot  be  denied  that  improve- 
ment sometimes  results  from  purely  lactovegetarian  food,  since  this 
general  nervous  irritability  becomes  quieted  and  the  special  gastric 
symptoms  are  removed,  although  there  is  no  proof  that  the  excessive 
secretion  becomes  lessened.  Hence  an  abundant  mixed  diet  should 
be  recommended,  with  plenty  of  albuminous  food.  Eggs,  milk,  cream 
cheese,  and  white  meat  of  chicken  or  turkey  should  supply  the  pro- 
tein needs  of  the  body.  These  meats  should  be  boiled,  broiled,  or 
baked,  and  prepared  with  little  or  no  condiments.  It  is  best  to  avoid 
the  dark  meats,  roast  beef,  steak,  chops,  etc.,  because,  according  to 
Bickel,  they  do  increase  the  secretion  markedly.  Fats  are  particularly 
advisable  for  hypersecretion,  provided  no  gastric  atony  exists,  because 
it  has  been  demonstrated  beyond  all  question  that  they  do  diminish 
secretion  and  their  caloric  value  is  greater  than  either  of  the  other 
two  varieties  of  food.  Our  success  has  been  greatest  with  unsalted 
butter;  the  middle  heavy  cream,  a  half  pint  of  which  should  be  taken 
daily;  olive  oil,  either  drunk  in  wineglass  doses  several  times  per  day 
or  eaten  on  bread,  as  the  Italians  do ;  the  yellow  fatty  cheese  or  emul- 
sion of  sweet  almond  oil,  two  tablespoonfuls  before  meals.  The  car- 
bohydrates should  be  given  in  the  form  of  white  bread  well  toasted  and 
vegetables  in  puree  form,  since  in  this  way  more  dia.stasie  action  will 
take  place  before  it  is  checked  by  the  rising  tide  of  acidity.     The  finer 


370  DISEASES   OF    THE   DIGESTIVE    TRACT 

forms  of  breakfast  foods  are  also  desirable,  those  made  from  wheat 
without  cellulose,  like  cream  of  wheat,  or  Indian  meal  porridge  being 
preferred,  which  also  serve  as  a  vehicle  for  large  quantities  of  cream 
and  sugar.  Sugar  also  forms  an  excellent  article  of  diet,  arouses  the 
secretion  of  the  diluting  fluid  (alkaline),  and  thereby  neutralizes  much 
of  the  excess  of  acid.  Our  preference  is  for  domino  sugar  or  good 
chocolates,  half  a  dozen  of  which  should  be  taken  in  the  midforenoon, 
midafternoon,  and  at  bedtime.  They  are  partieularlj^  convenient 
for  those  whose  occupation  does  not  allow  them  to  leave  their  busi- 
ness for  intermediate  meals.  Any  cooked  fruit  or  berries  without 
seeds,  cores,  or  peelings  (jellies,  sauces,  etc.)  are  also  beneficial,  be- 
cause they  combat  the  constipation,  which  is  so  objectionable.  Some 
find  that  cakes,  pies,  confections,  etc.,  arouse  an  attack  of  pyrosis,  but 
this  is  probably  due  to  the  poor  fat  in  the  one  case  and  the  nuts,  dates, 
etc.,  incorporated  in  the  other.  Eaw  fruits,  on  account  of  their  acids, 
or  more  particularly  because  the  most  of  them  in  the  market  are 
plucked  green  (oranges,  strawberries,  and  peaches)  and  are  ripened 
on  the  journey  to  place  of  sale,  are  borne  badly  by  these  patients. 
Milk,  or,  what  is  better,  egg  and  milk,  serves  admirably  to  neutralize 
the  excess  of  acid,  but  should  be  taken  as  a  supplementary  meal  and 
not  at  the  three  chief  meals,  where  the  food  serves  this  purpose  for 
two  or  more  hours.  Tea,  coffee,  alcoholics,  and  any  more  than  the 
most  moderate  use  of  tobacco  (two  cigars  daily)  should  be  forbidden, 
as  being  equally  as  injurious  as  the  meat  extracts.  It  is  probably 
more  advisable  to  allow  only  three  meals  daily,  so  as  to  keep  the  se- 
creting structure  at  rest  as  much  as  possible,  but,  as  patients  often 
complain  of  burning  between  these  meals,  it  is  better  to  have  three 
main  meals,  with  a  lunch  between  and  at  bedtime,  to  neutralize  the 
acid.  The  constipation  which  so  often  accompanies  this  condition, 
and  which  is  largely  responsible  for  it  in  many  cases,  cannot  be  treated 
by  purgatives,  which  always  increase  the  secretion.  At  best  we  are 
limited  to  agar-agar,  petroleum,  milk  sugar,  or  sodium  phosphate,  and, 
if  these  are  not  effective,  we  must  employ  an  enema.  Arranged  in  a 
table,  the  diet  reads  as  follows: 

DIET   LIST   IN    HYPERSECRETION   WITHOUT   ATONY   OR    STASIS. 

On  rising. — A  glass  of  Yichy  or  teaspoonful  of  sodium  phosphate  in 
a  cup  of  hot  water. 

Breal'fast. — Two  eggs  dropped  on  toast  (two  slices)  or  scrambled, 
or  crisp  bacon  and  baked  potato,  two  balls  of  fresh  butter,  and  some 
marmalade,  cocoa  made  with  milk. 


NERVOUS   DYSPEPSIA    (GASTRIC    NEUROSIS)  371 

11  a.  m. — Two  sandwiches  spread  thickly  with  cream  cheese,  or  six 
pieces  of  chocolate  candy  or  lumps  of  domino  sugar. 

Dinner. — Thick  soup  made  with  milk  and  flour  (potato,  pea,  or 
cream  of  celery,  etc.),  a  large  slice  of  the  white  meat  of  fowl,  or  veal 
or  calves'  brain,  or  broiled  cod  or  haddock,  Avith  two  pats  of  butter; 
vegetable  puree  (spinach,  cauliflower,  green  pease,  or  white  turnip), 
a  slice  of  toast  or  stale  bread. 

4  p.  m. — A  cup  or  bowl  of  custard,  or  the  candy  or  sugar  as  at  11 

A.  M. 

Supper. — An  omelet  or  picked  fish  or  sardines,  milk  or  buttered 
toast,  or  stale  rolls  with  fresh  butter,  cocoa  made  with  milk. 

Hot  baths  or  applications  of  towels  rung  out  of  hot  water  will  some- 
times allay  the  burning  sensation  when  it  comes  on  at  night,  but, 
other  than  this,  hydrotherapy  has  no  influence  over  the  secretion. 
Lavage  is  worthless  unless  the  hypersecretion  is  of  the  continuous 
variety — i.e.,  gastric  juice  is  found  in  the  fasting  stomach — or  there 
is  stasis;  accompanied  by  myasthenia,  lavage  is  worse  than  useless  to 
change  the  character  of  the  hypersecretion.  To  control  the  secretion, 
nothing  has  ever  been  discovered  better  than  belladonna  and  its  alka- 
loid, atropine,  or  modifications  of  the  same — eumydrine  and  methyla- 
tropine  bromide,  the  latter  in  doses  of  O.OOl-O.OOJr  gram  (^o-Hs 
grain).  The  alkalies  will  be  found  necessary  to  relieve  the  patient's 
distress,  but  nothing  curative  can  be  expected  from  them  alone.  Sev- 
eral examples  have  been  given  of  these  alkali  mixtures  under  medicinal 
treatment  (page  265).  Many  recommend  Merck's  magnesium  perhy- 
drol,  in  doses  of  0.5  gram  (8  grains)  in  the  form  of  tablets,  of  which 
one  is  to  be  taken  at  the  high  tide  of  secretion,  usually  two  hours  after 
eating,  or,  if  relief  is  not  obtained,  two  tablets  may  be  given.  Others 
have  recommended  the  use  of  hydrogen  peroxide,  of  which  a  teaspoon- 
ful  of  the  3  per  cent  solution  in  a  glass  of  water  is  to  be  taken  fasting. 
In  80  per  cent  of  all  cases  the  latter  is  said  to  bring  relief. 

b.  Diminution. — Diminution  of  secretion  easily  divides  itself  into 
subacidity,  or  hjq^ochlorhydria,  and  anacidity,  or  achlorhydria.  These 
are  mere  terms,  and  the  whole  classification  is  based  entirely  on  the 
activity  of  the  peptic  glands  of  the  stomach.  This  condition  is  un- 
doubtedly brought  on  by  nervous  depression,  and  varies  merely  in  de- 
gree. When  there  is  absence  of  hydrochloric  acid  and  diminished  but 
still  existing  ferments,  the  above  terms  are  used,  but,  when  both  hydro- 
chloric acid  and  ferments  vanish,  we  choose  to  apply  the  terms  origi- 
nated by  Einhorn — achylia  gastrica.  All  these  nervous  disturbances 
affect  the  secretion  of  gastric  juice,  but  apparently  its  hydrochloric 


372  DISEASES   OP   THE  DIGESTIVE   TRACT 

acid  more  than  its  ferment  constituents.  While  the  nervous  character 
of  this  suppression  will  often  in  a  blooming,  well-nourished  individual 
impress  itself  on  one  at  once,  it  is  never  justifiable  to  take  its  func- 
tional character  for  granted  until  all  means  have,  been  employed  to  ex- 
clude organic  disease,  like  gastritis  or  cancer. 

Symptoms. — The  symptoms  are  largely  pressure  after  eating,  loss  of 
appetite,  and  bad  taste  in  the  mouth.  Quite  often  there  may  be  sour 
eructations,  but  very  late  in  digestion  and  due  to  the  fatty  acids. 
There  is  almost  an  instinctive  demand  for  articles  of  sour  food,  lemons 
and  pickles  being  the  favorite,  or  some  patients  state  that  they  drink 
vinegar  with  satisfaction.  The  diagnosis  can  be  established  only  by 
several  examinations  of  the  gastric  contents,  by  which  hydrochloric 
acid  is  constantly  found  wanting;  there  is  no  excess  of  mucus,  the 
ferments  are  found  present,  but  diminished,  and  the  total  acidity, 
though  lessened,  does  not  reach  the  low  limit  of  achylia  gastrica  (10- 
15). 

Treatment. — The  treatment  is,  of  course,  directed  toward  endeavors 
to  increase  the  flow  of  gastric  juice,  and,  as  the  exciting  cause  is  of 
nervous  origin,  change  of  scene,  if  possible,  is  advisable.  One  of  the 
most  important  objects  to  accomplish  is  to  gain  the  confidence  of  the 
patient — to  learn  the  source  of  the  trouble.  Disappointment  in  love, 
jealousy,  and  suspicion  of  a  husband  unusually  attentive  to  ladies,  or 
chagrin  at  being  childless,  have  all  come  within  our  observation,  and 
just  here  the  Eddyites  and  Pentecostals  succeed  where  the  doctor  fails. 
Pawlow  has  discovered  a  list  of  articles  of  food  which  are  unusually 
active  in  promoting  secretion,  and  our  patients  should  be  urged  to  era- 
ploy  largely  in  their  diet,  raw  scraped  beef,  bouillon,  compressed  beef 
juice,  the  meat  extracts,  milk,  and  gelatine,  while  abundant  water 
drinking  can  also  be  recommended.  Condiments,  too — pepper,  mus- 
tard, catsup,  salt,  etc. — are  useful  in  exciting  the  flow,  and  should  be 
used  freely  with  food.  A  small  quantity  of  alcohol  is  also  desirable 
after  meals,  which  exercises  the  same  influence.  Of  medicines,  only 
hydrochloric  acid  or  acidol  has  any  influence  on  this  condition,  and 
should  be  given  in  large  doses  until  hydrochloric  acid  appears  in  the 
gastric  juice.  The  morning  cold  plunge  is  also  of  benefit,  whether  act- 
ing as  a  stimulant  to  the  nervous  system  or  on  secretion  directly  is  dif- 
ficult to  say. 

ACHYLIA  GASTRICA. 

Achylia  gastrica  is  characterized  by  a  complete  failure  of  the  gastric 
juice,  both  hydrochloric  acid  and  ferments  being  lacking;  hence  the 


NERVOUS  DYSPEPSIA    (GASTRIC   NEUROSIS)  373 

more  proper  term  would  be  apepsia  gastrica.     We  must  recognize  three 
distinct  types  of  this  anomaly,  dependent  on  its  causes : 

1.  The  congenital  form,  which  results  from  weakness  of  the  peptic 
glands. 

2.  An  acquired  form,  already  described,  which  is  due  to  gastritis,  or 
the  atrophic  form  accompanying  cancer,  in  which  the  glands  are  prob- 
ably destroyed. 

3.  That  resulting  from  pernicious  anemia. 

4.  The  neurotic  form,  which  accompanies  nervous  dyspepsia. 

The  differentiation  of  these  four  forms  may  be  very  difficult,  for 
neither  the  symptoms  nor  the  gastric  findings  differ. 

Symptoms. — The  symptoms  may  be  variable  or  utterly  wanting,  the 
reason  for  which  is,  as  has  been  often  mentioned,  that  the  duodenal  di- 
gestion may.  compensate  fully  for  a  faulty  or  lacking  gastric  one.  To 
accomplish  this,  however,  we  must  have  a  perfect  gastric  motility  and 
a  normal  duodenal  digestion.  Just  as  soon  as  the  motility  begins  to 
flag  and  food  in  a  state  of  partial  fermentation  makes  its  entrance  into 
the  intestine,  then  diarrhea  is  often  set  up,  (gastrogenous),  which  pro- 
duces so  much  emaciation  that,  with  the  other  symptom  (absence  of 
hydrochloric  acid),  we  may  look  on  our  patient  as  a  victim  of  cancer. 
An  examination  of  the  stool  will  show  large  quantities  of  connective 
tissue,  which  ordinarily  arouses  at  once  an  inference  of  lacking  gastric 
juice,  since  by  that  alone,  and  not  by  the  pancreatic  juice,  can  this  ma- 
terial be  digested.  As  explained  under  examination  of  feces,  this  is 
not  the  only  cause  of  undigested  connective  tissue,  but  it  is  the  most 
common.  We  have,  in  addition,  the  old  symptoms,  with  so  many  in- 
terpretations— pressure  and  distention  after  eating,  also  a  well-defined 
moderate  stabbing  pain  a  couple  of  hours  after  the  meals — which  re- 
minds one  of  hypersecretion  until  the  gastric  contents  are  examined. 
This  dolorous  sensation  is  said  to  be  due  to  the  mechanical  action  of 
the  coarse  unliquefied  food  fragments  upon  the  gastric  walls.  Pyrosis 
and  acid  eructations  may  also  be  present  one  to  two  hours  after  food 
is  taken,  also  making  one  think  of  hypersecretion  until  the  examination 
clears  the  matter  up.  Occasionally,  too,  the  achylia  causes  no  discom- 
fort and  is  only  accidentally  discovered.  In  two-thirds  of  all  instances 
there  is  no  irregularity  of  the  bowels,  but  there  may  be  constipation, 
and  very  rarely  we  may  have  these  persistent  diarrheas,  so  that  in 
case  of  the  latter  it  is  always  our  custom  to  investigate  the  gastric  diges- 
tion. As  often  mentioned,  the  hydrochloric  acid  stimulates  the  flow 
of  pancreatic  juice,  and,  when  this  is  absent,  we  may  have  also  a  veri- 
table achylia  pancreatica  and  the  feces  show  many  split  and  unsplit  fat 


374  DISEASES   OF   THE   DIGESTIVE   TRACT 

particles,  meat  fibers,  starch  remnants,  and  the  retention  of  connective 
tissue  nuclei.  One  is  also  astonished  at  the  enormous  amount  of  stool 
passed  by  an  achylic.  The  nutrition  suffers  because  of  this  great  loss 
of  nutrient  matter,  but  Ley,  who  followed  the  history  of  ninety-one 
achylics,  could  not  find  that  it  shortened  their  lives  to  any  extent. 
Furthermore,  he  emphatically  negatived  the  statement  often  made, 
that  the  loss  of  gastric  juice  caused  pernicious  anemia,  by  stating  that 
the  sequence  was  always  reversed — i.e.,  the  anemia  was  primary. 
Again,  the  suspicion  that  cancer  might  arise  from  achylia  was  nega- 
tived, since,  in  an  observation  of  fifty  achylics  over  40  years  ^of  age 
for  periods  of  one  to  fourteen  years,  he  had  never  seen  a  gastric  cancer 
arise. 

The  appearance  of  the  gastric  content  in  an  achylic  is  very  char- 
acteristic. It  can  barely  be  made  to  run  through  the  tube,  and  often 
only  a  few  cubic  centimeters  can  be  removed,  or  the  tube  must  be  with- 
drawn with  a  closed  end,  when  a  little  will  be  obtained,  in  which  the 
bread  is  simply  softened,  but  not  broken  up,  just  as  if  it  had  remained 
in  water  for  the  same  period  it  was  in  the  stomach.  The  inference 
that  the  gastric  motility  is  increased  and  the  rest  of  the  meal  has  passed 
into  the  duodenum  is  not  justified,  for,  if  the  tube  be  reintroduced  and 
the  stomach  washed  out,  all  the  bread  will  be  found ;  in  fact,  based  on 
the  discovery  of  Cannon,  that  the  pylorus  does  not  open  until  free 
hydrochloric  acid  is  established,  it  has  always  seemed  to  us  that  motility 
was  very  much  delayed.  Usually  the  gastric  juice  will  show  an  acid 
reaction  to  blue  litmus,  but  the  total  acidity  will  rarely  be  above  2-4 ; 
the  free  acid,  pepsin,  rennin,  and  mucus  are  all  wanting,  and  in  this 
absence  of  mucus  we  have  our  best  guide  in  excluding  gastritis  and 
early  cancer.  On  account  of  the  vulnerability  of  the  mucous  mem- 
brane, we  may  often  have  small  traces  of  blood  in  the  gastric  contents, 
but  never  in  the  feces,  according  to  our  experience.  Lactic  acid  is 
sometimes  found,  but  never  in  our  observation  when  it  could  not  be 
found  equally  as  well  in  the  bread  used  for  the  test  breakfast.  Taken 
altogether,  the  absence  of  hydrochloric  acid  and  ferments,  the  presence 
of  lactic  acid  and  a  trace  of  blood,  together  with  the  emaciation,  may  so 
confuse  one  that  some  study  of  the  progress  of  the  disease  may  be  neces- 
sary to  exclude  cancer  in  those  well  advanced  in  years.  Once  it  has 
fallen  to  us  to  recommend  an  exploratory  operation  in  such  a  case, 
which  disclosed  nothing  abnormal  in  the  stomach,  and  the  same  expe- 
rience has  fallen  to  others,  and  we  are  both  justified,  for  under 
analogous  circumstances  the  same  practice  of  early  exploratory  opera- 
tion has  enabled  us  to  ''nip  i'  the  bud"  an  early  cancer.     The  purely 


NERVOUS   DYSPEPSIA    (GASTRIC    NEUROSIS)  375 

nervous  form  is  usually  accompanied  by  symptoms  relating  more  to 
the  unstable  nervous  equilibrium — like  headaches,  sleeplessness,  and 
easily  aroused  agitation — than  to  the  stomach,  though  loss  of  appetite 
often  exists.  In  this  nervous  form,  too,  the  suppression  of  the  gastric 
juice  is  not  permanent,  as  on  repeated  examination  we  will,  without 
any  warning  or  change  in  the  patient's  nervous  condition,  find  a  sud- 
den return  of  the  hydrochloric  acid  and  ferments,  so  that  the  achylia 
is  only  a  symptom  rather  than  the  source  of  the  nervous  manifesta- 
tions. When  we  find  this  heterochylia,  we  may  conclude  at  once  that 
we  are  dealing  with  the  nervous  or  functional  variety. 

Treatment. — The  treatment  is,  first  of  all,  dietetic,  which  should 
consist  in  an  effort  to  present  the  food  in  such  a  finely  divided  condi- 
tion that  as  little  delay  as  possible  shall  take  place  in  the  stomach,  for, 
as  stated,  if  motility  is  unimpaired,  patients  do  not  apparently  suffer 
from  this  absence  of  gastric  digestion.  This  does  not  preclude  the  use 
of  meat,  but  it  should  always  be  employed  in  the  form  of  hash,  minced, 
or  as  Hamburger  steak,  lightly  broiled  and  served  with  butter,  much 
as  was  suggested  for  ectasia.  Peptones  and  albumoses  have  been 
recommended,  but  are  undesirable  in  any  amount,  for  they  are  bitter, 
and  no  patients  are  more  finicky  about  the  flavor  of  food  than  achylics, 
and,  in  addition,  these  predigested  proteins  are  liable  to  incite  the  diar- 
rhea, which  is  so  common  in  this  disease.  ^luch  more  desirable  are 
the  grain,  casein,  and  meat  powders,  like  gliadine  and  laibose,  which 
may  be  taken  on  bread  well  spread  with  butter,  in  milk,  soup,  etc. 
The  carbohydrates,  unless  in  the  finest  form,  also  suffer  in  their  diges- 
tion because  the  digestive  juice  is  lacking  to  attack  the  gluten,  so  that 
the  ptyalin  may  assail  the  starch.  As  long  as  the  motility  is  unim- 
paired, we  may  add  fats  in  the  form  of  cream,  butter,  and  milk,  and 
in  the  form  of  thick  soups,  bowl  custard,  ice  cream,  etc.  These  means 
are  employed  simply  to  offer  the  duodenum  properly  prepared  pabulum 
for  its  activities,  and  not  to  restore  the  secretion  of  the  gastric  juice, 
which  is  equally  beyond  our  control,  whether  of  the  erratic  nervous 
variety,  which  comes  and  goes  as  it  will,  or  the  congenital  type,  which 
never  returns.  During  the  periods  of  diarrhea  special  care  must  be 
taken  of  the  diet,  which  for  a  few  days  may  have  to  be  restricted  to 
barley  and  sago  soup,  boiled  milk,  and  flour  gruel.  Nothing  can  be 
more  unjustified  than  that  physicians  should  give  raw  scraped  meat 
to  overcome  the  anemia  of  an  achylic,  when  the  six  to  eight  daily 
movements  of  the  patient  are  made  up  almost  wholly  of  meat  fiber  and 
connective  tissue,  as  has  come  within  our  observation.  The  diet  best 
adapted  is  the  one  given  under  Chronic  Gastritis,  with  suppression  of 


376  DISEASES   OF   THE   DIGESTIVE    TRACT 

hydrochloric  acid  (page  302),  since  motility  is  not  impaired  in  either 
condition  and  need  not  be  taken  into  consideration.  In  all  cases  where 
secretion  fails,  only  large  doses  of  dilute  hydrochloric  acid  are  indi- 
cated— not  to  restore  the  lost  secretion,  but  to  stimulate  the  pancreas  to 
greater  activity  and  to  check  the  diarrhea,  for  which  it  is  the  best 
remedy.  Cold  baths  and  sprays  will  alleviate  these  associated  nervous 
sensations,  but  will  not  help  the  gastric  condition,  and,  in  our  judg- 
ment, pankreon  and  extract  of  pancreas  are  not  called  for  unless  there 
is  a  marked  fatty  diarrhea,  which  sometimes  occurs. 

DISTURBANCES  OF  MOTILITY. 

Disturbances  of  motility  separate  themselves  naturally  into  increase 
and  diminution : 

a.  Increase. — An  increase  may  be  found  in  a  number  of  conditions, 
which  are  generally  termed  by  the  laity  either  "cramps"  or  ''heav- 
ing, ' '  since  they  manifest  themselves  either  by  pain  or  vomiting. 

Cardiospasm. — Cardiospasm  is,  perhaps,  the  most  common  condition 
found  in  a  large  clinic,  where  it  is  variously  complained  of  as  a  sticking 
of  food  in  the  throat  and  pain  in  the  heart,  arousing  in  the  patient's 
mind  suspicions  of  cardiac  trouble,  but  coming  after  meals  and  not  on 
exercise.  The  exciting  cause  is  often  hasty  eating,  swallowing  of  fluids 
rapidly  with  the  admixture  of  large  quantities  of  air,  and  the  ingestion 
of  hard  fragments  like  an  unmasticated  crust  of  bread  may  bring  it  on. 
This  cramp  of  the  cardia  is  seen  to  perfection  in  hysterics  and  neuras- 
thenics, in  whom  after  previous  nervous  disturbances  an  attack  may 
come  on.  These  attacks  are  extremely  sudden,  and  consist  of  a  drawing, 
tearing  pain,  experienced  under  the  breastbone  and  extending  to  the 
backbone.  The  spasm  may  be  relieved  in  a  few  moments  or  may  be  suc- 
ceeded by  others,  and  whether  the  effect  is  due  to  the  ability  of  different 
patients  to  withstand  pain  it  is  difficult  to  say,  but  the  appearance  may 
vary  from  a  sense  of  vague  discomfort  to  actual  suffering,  in  which 
perspiration  breaks  out  profusely  on  the  victim 's  face.  As  long  as  the 
spasm  lasts  the  sufferer  makes  constant  efforts  at  vomiting  until  at  last 
an  eructation  of  gas,  or  the  discharge  of  some  fluid  containing  mucus, 
with  a  few  food  fragments,  brings  relief,  which  is  aided  by  hot  carmina- 
tive (peppermint)  drinks,  or  it  may  be  necessary  to  employ  morphine. 
The  opinion  of  many,  that  above  the  contracted  portion  of  the  esopha- 
gus food  may  accumulate  and  by  stagnation  produce  secondary  esopha- 
geal changes,  is  probably  unfounded  when  the  spasm  is  purely  of  func- 
tional origin.     The  great  error  in  our  way  in  such  cases  is  to  accept 


NERVOUS   DYSPEPSIA    (GASTRIC   NEUROSIS)  377 

them  always  as  functional,  which,  of  course,  in  the  vast  majority  they 
are,  but  the  exceptional  ease  is  due  to  ulcer  or  malignant  disease  of  the 
cardia,  and  every  phj^sician  must  experience  some  chagrin  when  he 
learns  that  he  has  left  the  true  condition  to  be  discovered  by  another. 
In  all  cases  of  cramp  of  the  cardia,  whether  a  mere  lump  in  the  throat 
is  complained  of  or  an  attack  so  severe  that  it  may  arouse  suspicion  of 
angina  pectoris,  it  is  our  invariable  custom  to  pass  the  tube,  and,  if 
the  narrowing  is  fimctional,  the  largest  tube  will  pass  as  readily  as  the 
one  of  least  caliber,  but  not  so  if  organic  disease  is  present,  where  the 
smallest  one  reaches  the  stomach  best.  Streaks  of  blood  on  the  end  of 
the  tube  also  establish  promptly  the  diagnosis.  A  radiogram  is  of 
great  assistance  in  diagnosis,  but  is  not  to  be  relied  on  implicitly. 

Treatment. — The  treatment  is  often  begun  and  ended  with  the 
passage  of  a  large  sound  or  tube,  for  the  fear  of  obstruction  in  the 
esophagus  is  an  important  element  in  continuing  the  difficulty.  After 
one  attack  the  patient  should  be  warned  against  hasty  eating,  rapid 
drinking,  or  swallowing  hard  masses,  as  well  as  very  hot  or  very  cold 
fluids.  When  ulcer  or  fissure  of  the  cardia  exists,  the  ulcer  treatment 
must  be  employed.  Our  only  case  of  this  character  showed  the  peculi- 
arity of  clear  wash  water  at  first  from  the  fasting  stomach,  which 
quickly  changed  to  blood-stained  fluid  on  employment  of  successive 
portions  of  water,  while  the  feeling  of  constriction  and  pain  was  mid- 
way of  the  sternum  and  just  to  the  right  of  it.  The  treatment  of  the 
purely  functional  form  is  undoubtedly  the  introduction  of  large  sounds, 
which  are  allowed  to  remain  sometime,  or  recently  a  collapsed  rubber 
ball  has  been  devised  which  is  introduced  into  the  stomach,  inflated  and 
withdrawn,  thereby  markedly  dilating  the  customary  point  of  con- 
traction. A  wineglass  of  oil  before  each  meal  will  help,  while  bella- 
donna, bromide,  and  validol  allay  the  symptoms.  These  cases  are, 
many  times,  obstinate  and  onl}^  by  improving  the  general  health  of  the 
patient  can  a  cure  be  attained. 

Pylorospasm. — Pylorospasm,  or  painful  spasm  of  the  pylorus,  is  ap- 
parently either  primary,  dependent  on  hypersecretion,  particularly 
when  the  stomach  is  free  from  food,  as  in  the  early  morning  hours,  a 
condition  which  is  denied  by  some ;  or  secondary,  due  to  fissure  or  ulcer 
situated  at  the  pylorus.  The  excess  of  hydrochloric  acid,  however, 
plays  an  important  part  in  its  production,  for  it  is  vastly  more  com- 
mon when  the  acid  is  in  excess  than  when  absent — for  instance,  in  the 
later  stages  of  cancer.  The  older  view  that  a  spasmodic  contraction  of 
the  pylorus  occurs,  hy  which  the  food,  remaining  longer  in  the  stomach, 
produces  hypersecretion,  will  have  to  be  given  up,  for  the  consensus  of 


378  DISEASES   OF   THE   DIGESTIVE   TRACT 

opinion  is  that  hypersecretion  is  primary  and  the  contact  of  the  excess 
of  acid  with  an  erosion  causes  repeated  long  continued  and  painful 
closure  of  the  orifice,  by  means  of  which  stasis  and  increased  peristalsis 
of  the  stomach  may  arise.  It  is  also  very  possible,  as  previously 
explained,  that  the  fissure  itself  produces  hypersecretion,  so  that  a 
vicious  circle  results.  That  this,  in  turn,  may  lead  to  ectasia  is  pos- 
sible ;  that  any  purely  functional  increase  in  the  secretion  of  gastric 
juice  may  ever  lead  to  such  dire  results  is  improbable.  At  the  times 
of  examination  there  may  be  no  difference  in  the  dilatation  produced 
by  organic  pyloric  narrowing  and  spasm  from  fissure,  but  the.  latter 
condition  may  improve  and  stasis  temporarily  disappear,  but  the 
former  condition  is  permanent. 

Symptoms. — The  symptoms  consist  of  a  boring,  burning  pain  in  the 
epigastrium,  which  extends  to  both  sides  along  the  costal  borders  to  the 
back,  so  intense  that  vomiting  results  either  from  the  pain  or  from  the 
increased  peristalsis  of  the  stomach,  which  find  a  less  resisting  obstacle 
at  the  cardia  than  at  the  pylorus.  The  vomitus  is  excessively  acid, 
and,  after  the  act,  relief  is  usually  obtained.  In  earlier  days- we  used 
to  consider  these  attacks  as  manifestations  of  some  of  the  various  forms 
of  neuralgia,  hence  called  gastralgia,  particularly  when  vomiting  did 
not  occur,  but  they  probably  all  have  the  same  pathology.  On  ac- 
count of  the  late  appearance  of  the  pain  after  food  is  taken,  the  patient 
is  often  thought  to  be  suffering  from  duodenal  ulcer,  but  there  is 
no  regularity  in  the  former  as  there  is  in  the  latter.  When  marked 
stasis  occurs,  as  demonstrated  by  the  presence  of  sarcinae,  it  seems  to  us 
that  it  cannot  be  due  to  these  spasmodic  contractions,  but  to  true 
stenosis. 

Treatment. — The  best  treatment  to  employ  is  that  given  for  real 
ulcer,  consisting  of  rest  in  bed  and  the  appropriate  diet.  This  has 
brought  relief  in  our  practice  when  the  patient  had  actually  been  re- 
moved to  the  hospital  for  a  gastroenterostomy  and  a  few  days  had  been 
allowed  to  elapse  before  the  operation.  The  oil  treatment  has  also  been 
very  effective  in  staying  the  attacks  of  pain,  whether  by  its  soothing 
effect  on  the  lesion  or  lessening  the  secretion  cannot  be  stated  with  ac- 
curacy, although  the  repeated  examination  of  gastric  contents  shows 
no  diminution  in  this  secretion.  If  the  patient  objects  to  the  use  of  the 
oil,  which  has  never  occurred  to  us  (a  half  glassful  being  taken 
readily),  it  may  be  put  up  in  the  form  of  an  emulsion  Avith  menthol,  or 
use  the  emulsion  called  egmol,  which  has  only  one  disadvantage — the 
presence  of  a  small  quantity  of  brandy.  As  moderate  emaciation  is 
usually  present  with  these  repeated  attacks  of  pyloric  spasm,  the  oil 


NERVOUS   DYSPEPSIA    (GASTRIC    NEUROSIS)  379 

fulfills  a  second  indication — the  improvement  of  nutrition.  The  purely 
neurotic  form  of  spasm,  if  such  exists,  cannot  be  at  once  differentiated, 
and  such  treatment  may  be  employed,  but  usually  with  little  relief,  so 
that  one  must  have  recourse  to  the  usual  means  of  allaying  hyperex- 
citability  of  the  nervous  system — validol,  bromide,  hot  hip  baths  at 
bedtime,  and  every  means  for  improving  the  nutrition  of  the  patient. 
Apart  from  the  persistent  use  of  oil,  the  diet  will  not  differ  from  that 
given  for  ectasia  with  hypersecretion  (page  331), 

Eructatio  Nervosa. — Eructatio  nervosa  (aerophagy)  consists  of 
loud  explosions  of  gas  from  the  esophagus,  which  may  or  may  not  come 
from  the  stomach,  because  some  individuals  can  draw  the  air  into  the 
former  and  eject  it  without  its  entering  the  stomach  at  all.  This  is  en- 
tirely different  from  the  almost  silent  eructations  of  fermentative  or 
putrefactive  gases,  as  is  found  in  those  suffering  from  actual  gastric 
disease.  The  true  nervous  eructations  take  place  without  any  refer- 
ence to  food,  though  more  apt  to  occur  directly  after  eating,  especially 
when  that  act  follows  anger,  grief,  or  fright.  The  act  must  always  be 
accompanied  by  previously  swallowed  air,  whether  the  patient  is  con- 
scious of  it  or  not,  but  if  such  patient  is  told  to  "belch"  (the  usual 
term  employed)  without  his  mouthful  of  air,  he  cannot  accomplish  it, 
and  calling  his  attention  to  this  may  break  up  the  habit.  There  is  al- 
ways a  concomitant  feeling  of  distress  in  the  stomach,  which  the  victim 
tries  to  relieve.  This  is  a  little  different  from  the  second  variety, 
where  the  air  swallowed  is  held  by  the  spasmodic  closure  of  the  pharyn- 
geal muscles  until  the  tension  in  the  esophagus  and  stomach  exceeds 
their  strength,  when  a  gatling  gun  series  of  explosions  occur  until  the 
tension  is  relieved.  Our  earliest  recollection  is  of  an  elderly  woman 
w^ho  used  to  go  outside  of  her  cottage  after  supper,  and  while  standing 
there  made  the  welkin  ring  with  her  explosions,  which  in  the  still  night 
air  of  a  quiet  farming  district  was  doubly  effective  and  aroused  much 
sympathy  among  her  neighbors  for  the  sufferer,  which  is  probably  why 
she  chose  the  open  for  her  act.  These  attacks  are  apt  to  occur  at  regu- 
lar intervals  during  the  day,  but  never  at  night.  The  act  of  swallow- 
ing the  air  is  so  imperceptible  that  it  almost  escapes  the  observation  of 
the  patient,  but.  if  his  attention  is  called  to  it  and  he  is  fairly  intelli- 
gent, he  may  detect  his  act  for  the  first  time.  This  ingestion  of  air 
can  be  much  more  easily  determined  with  a  stethoscope  placed  over  the 
epigastric  angle  or  in  the  back,  when  the  air  bubbles  can  be  easily  heard 
descending  the  esophagus  in  a  series  of  gurgling  sounds.  It  has  seemed 
to  us  that  sufferers  from  gastric  atony  and  ptosis  were  oftener  victims 
of  this  habit  than  any  others,  and  Linossier  believes  that  an  aspira- 


380  DISEASES   OF   THE   DIGESTIVE   TRACT 

tion  of  air  can  take  place  by  which  it  is  drawn  into  a  relaxed  stomach 
on  descent  of  the  diaphragm  with  closed  glottis  just  as  into  the  bronchi. 
The  frequency  of  these  paroxysms  varies  greatly.  In  the  case  men- 
tioned, once  a  day  sufficed;  others  indulge  in  only  an  occasional  and 
single  act,  but  not  enough  to  induce  them  to  consult  a  physician; 
others,  on  the  contrary,  constantly  feel  distention  in  the  epigastrium, 
and  are  relieved  by  a  paroxysm,  when  they  begin  the  succession  of 
swallowing  again,  like  a  pouter  pigeon,  until  they  avoid  their  friends 
from  chagrin  and  life  becomes  a  burden  to  them.  When  this  ingested 
air  can  be  easily  ejected,  perhaps  no  harm  comes  from  it,  but  the  con- 
dition is  often  associated  with  cardiospasm,  and  then  the  gastric  dis- 
tention may  become  very  painful;  the  pressure  can  be  roughly  esti- 
mated by  the  roar  of  air  which  meets  one  when  a  stomach  tube  is  intro- 
duced. Furthermore,  there  may  also  be  associated  an  intestinal  flatul- 
ency, which  causes  great  discomfort  and  which  is  relieved  by  the  free 
passage  per  anus  of  gas,  which  is  absolutely  nothing  more  unquestion- 
ably than  swallowed  air.  Another  complication  of  this  ingestion  of 
air  is  the  pressure  exerted  upon  the  heart,  which  causes  intermission  of 
its  beat  and  thereby  alarms — ^beyond  measure  the  excitable  patient.  In 
the  clinic  we  often  see  cases  where  dyspnea  and  mild  asthmatic  attacks 
occur  dependent  on  nothing  else  than  distention  of  the  stomach  by  this 
swallowed  air.' 

Treatment. — The  treatment  of  aerophagy  may  be  either  the  most 
satisfactory  or  the  most  difficult  that  can  be  imagined.  If  the  patient 
is  intelligent  and  can  be  shown  that  only  that  air  is  ejected  which  is 
swallowed,  then  a  little  practical  instruction  will  often  cure  the  indi- 
vidual. In  the  ignorant  class,  however,  it  is  impossible  to  convince 
them  that  they  do  swallow  air,  and  they  always  insist  that  they  obtain 
relief  from  their  efforts  at  ejection.  If  asked,  however,  to  eject  with 
the  mouth  open,  the  dullest  patient  will  soon  see  that  it  cannot  be  done. 
Zweig  recommends  what  he  calls  ''compression  massage"  of  the 
stomach,  which  consists  of  compressing  the  stomach  with  both  hands 
firmly  during  expiration  and  then  have  the  patient  breathe  deeply  ten 
to  twenty  times  with  the  hands  in  this  position.  If  this  suggestive 
treatment  is  of  no  avail,  then  we  must  employ  all  the  means  of  modern 
treatment  of  the  nervous  condition,  consisting  of  sedatives,  hydro- 
therapy, massage,  and  electricity.  In  the  better  classes  this  treatment 
can  be  carried  out  only  in  a  sanitarium,  where  very  often  its  effects  are 
most  brilliant.  Without  this  we  have  to  rely  largely  on  validol, 
sodium  bromide,  and  chloroform  water,  which  at  least  relax  the  spasm 
of  the  pharyngeal  muscles  and  allow  the  air  to  escape  readily.     For 


NERVOUS  DYSPEPSIA    (GASTRIC   NEUROSIS)  381 

the  most  obstinate  cases,  only  the  repeated  passage  of  the  stomach  tube 
or  sound  will  avail,  which,  as  one  can  readily  see,  is  merely  a  method 
of  suggestive  therapeutics.  When  the  patient  is  reduced  in  flesh,  very 
often  a  process  of  overfeeding,  by  which  a  few  pounds  are  gained,  will 
also  succeed. 

Nervous  Vomiting. — Nervous  vomiting  is  caused  either  by  cerebral 
or  spinal  agencies,  or  may  be  wholly  reflex.  Cerebral  vomiting  is 
often  found  in  pathologic  conditions  of  the  brain  and  its  envelopes 
(tumor,  concussion,  meningitis,  etc.),  intoxications  (opium,  morphine, 
and  tobacco),  as  well  as  in  nephritis  (uremia).  Vomiting  of  spinal 
origin  is  almost  invariably  the  result  of  tabes  dorsalis,  generally  termed 
gastric  crises.  This  last  is  characterized  by  severe  pains  in  the  epi- 
gastrium, with  persistent  vomiting  that  may  last  from  two  to  three 
days  and  produce  in  the  patient  the  most  intense  prostration.  The  at- 
tacks may  follow  each  other  in  rapid  succession,  or  periods  of  a  month 
may  elapse  between  them.  During  the  interval  the  patient  usually 
feels  in  perfect  health,  and  if  examined  during  this  time  we  may  find 
all  the  stigmata  of  tabes,  ataxia,  sluggish  pupils,  and  inability  to  stand 
erect  with  eyes  closed,  or  none  of  these  may  be  elicited.  This  nervous 
vomiting  may  be  one  of  the  earliest  symptoms,  and  the  other  evidences 
of  sclerosis  occur  months,  or  even  years  later.  A  case  came  acci- 
dentally under  our  observation  where  the  appendix  had  been  re- 
moved, and  an  exploratory  operation  with  the  ultimate  intention  of 
establishing  a  gastroenterostomy  for  a  suspected  pyloric  ulcer  had  been 
performed  without  any  evidence  of  scar,  in  whom  later  the  clear,  un- 
mistakable signs  of  tabes  were  found.  Many  of  these  patients,  too, 
have  the  appearance  of  the  habitus  asthenicus,  and  it  may  be  interest- 
ing to  observe  whether  those  patients,  when  later  tabes  develops,  are 
especially  inclined  to  these  gastric  crises.  Similar  gastralgic  attacks 
have  been  observed  in  sclerosis  of  the  spinal  cord  or  in  myelitis.  It  is 
for  us,  however,  to  deal  only  with  those  cases  of  nervous  vomiting  which 
occur  in  hysterical  and  neurasthenical  individuals,  bearing  in  mind 
always  the  possibility  of  confusion  with  reflexes  from  actual  disease  of 
the  spinal  cord.  Many  instances,  too,  occur  where,  like  the  concomi- 
tant nervous  dyspepsia,  the  reflex  comes  from  diseased  genital  organs. 
In  children,  also,  we  may  observe  this  periodical  vomiting,  accompanied 
by  a  marked  acetone  odor  of  the  breath,  in  whom  not  a  single  evidence 
of  real  gastric  disease  can  be  discovered.  These  small  patients  often 
show  signs  of  extreme  pallor  as  well  as  widely  dilated  pupils,  and  the 
heart  beats  diminish  to  six  per  minute, — all  evidences  of  a  marked 
vagatonus.     Such  children,  provided  they  are  of  school  age,  should  be 


382  DISEASES   OF   THE   DIGESTIVE   TRACT 

immediately  removed  from  school  and  given  the  most  energetic  robo- 
rant  treatment  possible,  with  special  attention  to  diet,  which  should  in- 
clude an  increased  proportion  of  fat.  The  true  nervous  vomiting  is 
particularly  noted  for  the  ease  with  which  it  occurs,  its  freedom  from 
nausea,  the  blooming  and  well-nourished  appearance  of  the  victim,  and 
its  lack  of  dependence  on  the  nature  or  quantity  of  the  food.  Its 
causation  by  shock,  anger,  or  grief,  with  entire  absence  of  an  anomaly 
of  motility  or  secretion  on  the  part  of  the  stomach,  is  also  character- 
istic. It  can  be  readily  seen,  however,  that  one  should  never  make  a 
"snap"  diagnosis  of  nervous  vomiting  without  having  carefully  ex- 
amined the  nervous  system,  the  stomach,  and  genital  organs. 

Treatment. — The  treatment  is  most  unsatisfactory,  and  can  practi- 
cally never  be  successfully  carried  out  without  the  removal  of  the  pa- 
tient from  his  family  surroundings  to  a  health  resort  or  to  a  well-con- 
ducted sanitarium.  Friends  should  be  forbidden  admission  to  the  pa- 
tient, and  the  diet  should  consist  at  first  largely  of  milk,  taken  in  table- 
spoonful  quantities,  and  the  victim  should  remain  in  bed.  Sodium 
bromide  in  gram  (15  grains)  doses  three  times  per  day  and  the  occa- 
sional passage  of  the  stomach  tube  or  sound  will  overcome  the  irrita- 
bility of  the  vomiting  centers.  If  these  milder  means  fail,  one  can  al- 
w^ays  have  recourse  to  atropine  sulphate,  of  which  1  milligram  should 
be  injected  daily,  and  the  hypodermic  method  is  always  more  satisfac- 
tory because  of  its  suggestive  therapeutic  effect.  The  remarkable  ef- 
fects of  atropine  treatment  in  checking  nervous  irritability  was  first 
brought  to  our  attention  in  the  many  Keeley  cures  which  were  estab- 
lished at  one  time,  and  in  w^hich,  not  the  popularly  supposed  "gold," 
but  atropine,  was  employed.  Still,  to  our  sorrow^,  it  must  be  confessed 
that,  with  most  energetic  treatment,  these  patients  under  the  slightest 
nervous  disturbances  will  again  begin  to  vomit. 

b.  Diminution. — Gastric  atony  is  one  of  the  commonest  of  the  ills  of 
the  dyspeptic.  It  may  be  due  either  to  a  weakness,  by  which  the 
stomach  cannot  close  firmly  on  its  contents,  or  an  inability  of  the  organ 
to  force  the  food  into  the  duodenum,  by  which  it  remains  an  undue 
length  of  time  in  the  former.  This  period  is  only  relative,  however, 
for  the  fasting  stomach  in  the  morning  is  always  free  from  food  rem- 
nants, a  factor  which  differentiates  this  condition  from  the  true  dilata- 
tion, where  there  is  always  a  morning  residue.  This  condition  never 
exists  alone,  but  in  conjunction  with  a  general  loss  of  tone  of  both  nerv- 
ous and  muscular  system,  and  may  be  induced  by  long  illnesses,  like 
typhoid,  tuberculosis,  syphilis,  and  suppuration.  Then,  again,  we  see 
many  cases  Avhere  no  cause  can  be  found,  and  from  complaints  of  dys- 


NERVOUS   DYSPEPSIA    (GASTRIC    NEUROSIS)  383 

pepsia  and  persistent  constipation  since  childhood  we  are  forced  to  be- 
lieve that  the  predisposition  is  congenital.  Atony  may  also  accompany 
gastric  ulcer,  intestinal  and  gastric  catarrh,  and  cholelithiasis,  but  the 
atony  is  always  primary,  dependent  on  general  loss  of  muscular  tone. 

Sjnnptoms. — The  symptoms  comprise,  first,  an  early  sense  of  full- 
ness in  the  stomach  long  before  the  appetite  is  satisfied  and  a  following 
period  of  pressure  and  discomfort — as  patients  often  express  it,  "a 
slow  digestion."  Then,  too.  there  are  often  eructations  of  air,  or  at 
times  a  mouthful  of  food  will  be  brought  up  a  long  time  after  the  meal 
is  taken.  Patients  also  declare  that  after  the  usual  interval  between 
meals  (five  to  six  hours)  they  are  conscious  of  food  still  remaining  in 
the  stomach.  Vomiting,  too,  may  occur  when  too  hearty  a  meal  is 
taken,  but  is  not  at  all  constant.  Headache,  and  particularly  dizziness 
or  vertigo,  may  be  experienced  when  a  change  of  position  from  the 
prone  or  sitting  to  the  erect  takes  place,  and  they  may  also  have  a 
fainting  sensation  under  similar  conditions.  Insomnia  may  accom- 
pany, and  the  victims  are  always  undernourished.  Many  of  these  pa- 
tients show  the  physical  signs  of  enteroptosis,  flat  abdomen,  long,  nar- 
row chest,  and  acute  substernal  angle.  Yet,  we  must  not  lose  sight  of 
the  fact  that  an  occasional  atonic  is  found  who  is  well  nourished,  has  a 
normal  build,  and  abdominal  organs  in  their  usual  site.  The  size  and 
position  of  the  stomach  can  be  best  elicited  by  the  succussion  which  in 
these  patients  can  be  easily  aroused  on  account  of  the  thinness  of  the 
abdominal  walls.  Even  when  the  stomach  is  in  its  normal  position, 
slight  relaxation  of  its  walls  will  bring  its  lower  border  somewhat  be- 
low the  usual  site.  Still,  the  mere  presence  of  succussion  alone  cannot 
be  utilized  to  diagnose  an  impaired  motility.  Atony  is  always  under- 
stood as  a  condition  in  which  food  remains  an  unduly  long  time  in  the 
stomach,  so  that  an  hour  after  a  test  breakfast  we  do  not  find  the  usual 
150-250  c.c.  according  to  the  method  of  determining  the  total  contents 
given  on  page  140,  but  a  much  larger  quantity.  No  diagnosis  of  im- 
paired motility  should  be  accepted  unless  this  increase  occurs.  Zweig 
and  Eisner  have  found  that  only  50  c.c.  of  fluid  are  sufficient,  in  con- 
junction with  air,  to  produce  loud  succussion  sounds  over  the  stomach, 
so  that  both  factors,  increased  volume  and  these  sounds,  must  be  pres- 
ent for  a  diagnosis.  Then,  too.  the  increased  volume  does  not  neces- 
sarily mean  atony,  for  in  hypersecretion  there  is  always  a  large  volume, 
and  those  so  affected  may  emit  loud  succussion  notes  without  impaired 
motility.  Furthermore,  it  is  not  unusual  to  find  increased  volume  of 
contents  and  loud  succession  in  ectasia,  with  pyloric  stenosis,  where  the 
motility  is  increased  to  such  an  extent  that  rigidity  may  be  observed. 


384  DISEASES   OF   THE   DIGESTIVE   TRACT 

In  short,  we  may  say  that  the  conditions  in  impaired  motility  are  di- 
rectly the  reverse  of  those  in  hypersecretion — that  is,  the  difference  in 
the  acidities  is  greater  than  20.  The  residue  by  centrifugation  is  two- 
fifths  or  more  of  the  total  volume,  and  the  hydrochloric  acid  in  the  con- 
tents withdrawn  and  the  wash  water  is  less  than  80.  The  mere  rela- 
tive amount  of  hydrochloric  acid  may  be  normal,  or  slightly  increased 
on  account  of  the  greater  stay  of  the  food  in  the  stomach.  As  stated, 
the  morning  fasting  stomach  must  always  be  free  from  food,  but  to  ob- 
tain the  actual  degree  of  impairment  we  may  give  a  Riegel  meal  and 
remove  the  contents  six  to  seven  hours  afterward,  when  the  normal 
stomach  should  be  empty.  The  atonic  stomach  also  shows  certain 
peculiarities  under  the  x-ray  examination.  The  buttermilk  holding  the 
bismuth  in  suspension  falls  promptly  into  the  caudal  end  of  the 
stomach  without  filling  the  organ  fully;  there  is  a  much  larger  air 
bubble  at  the  summit,  and  the  stomach  requires  a  much  longer  period 
than  usual  to  empty  itself.  Atony  of  the  stomach  is  very  erratic  in  its 
behavior.  AYe  have  periods  of  perfect  health  until  some  mental  strain 
or  shock — loss  of  relatives  or  a  slump  in  the  stock  market — brings  on 
another  period  of  dyspeptic  symptoms.  It  has  always  seemed  to  us 
that  if  the  weight  of  the  individual  prone  to  atony  could  be  main- 
tained, this  was  always  the  best  insurance  against  the  digestive  mani- 
festations. As  stated  before,  the  outcome  of  atony  is  never  dilatation, 
except  in  those  rare  instances  where  a  congenital  gastroptosis  causes  a 
kinking  of  the  pylorus  and  difficulty  in  the  egress  of  food.  All  that 
can  be  done  to  avoid  the  ill  results  of  myasthenia  gastrica  is  to  induce 
individuals  thus  afflicted,  recovering  from  acute  illnesses  to  begin,  at 
the  earliest  date  which  is  safe,  with  an  abundant  diet  containing  a  large 
percentage  of  fat,  and  induce  women  after  confinement  to  demand  their 
two  Aveeks  of  rest  in  bed  and  a  week  more  for  good  measure. 

Treatment. — The  treatment  of  atony  resolves  itself  into  one  almost 
wholly  of  overnutrition.  This  is,  however,  no  easy  task  for  the  pa- 
tients are  lacking  in  appetite  and  fearful  of  food  because  of  the  dis- 
tress it  causes  them,  and,  from  restrictions  imposed  by  physicians  or 
self-imposed,  are  always  undernourished.  If  complete  change  in  oc- 
cupation and  surroundings  cannot  be  made  for  a  time,  which  is  often 
impossible  for  business  reasons,  one  must  be  very  peremptory,  almost 
schoolmaster-like,  in  directions  and  injunctions,  not  only  to  the  quality 
of  food,  but  also  as  to  its  quantity.  Then,  too,  the  long-continued 
habits  of  the  individual,  often  as  well  grounded  as  the  laws  of  the 
Medes  and  Persians,  have  to  be  changed,  and  often  against  the  protests 
of  the  invalids,  who  insist  that  never  in  a  long  life,  of  which  the  years 


NERVOUS   DYSPEPSIA    (GASTRIC    NEUROSIS)  385 

are  usually  stated  with  emphasis,  has  a  luncheon  ever  been  indulged 
in.  Now,  the  intermediate  small  meals  or  lunches  are  the  basis  of 
hypernutrition,  and  must  be  insisted  on.  Therefore,  finally  the  pa- 
tient, in  a  resigned  voice,  consents,  but  with  the  reservation  that  the 
evils  confidently  believed  to  accompany  the  revolution  in  habits  will 
rest  on  the  physician's  head.  Some  propose  an  exclusive  milk  diet, 
three  and  four  quarts  daily  being  recommended.  Now,  no  nervous 
dyspeptic,  whose  main  complaint  was  atony,  ever  received  the  slightest 
benefit  from  these  large  quantities  of  milk,  as  its  bulk  is  absolutely  op- 
posed to  a  weakened  musculature  which  must  pass  it  along.  A  dry 
diet  has  also  had  its  advocates,  but,  as  shown  under  Ectasia,  the 
stomach  can  provide  sufiicient  diluting  fluid  and  gastric  juice  to  bring 
up  the  volume  at  the  end  of  an  hour  to  the  same  amount,  whether  dry 
or  liquid  food  is  taken,  so  that  the  former  has  no  advantage.  The  diet, 
then,  must  contain  the  three  ingredients — carbohydrates,  fats,  and 
protein — but  particularly  the  latter  two,  and  in  such  form  that  their 
passage  through  the  stomach  should  not  be  delayed.  Vegetables 
mashed,  fruits  cooked,  meats  and  fish  hashed  or  minced,  and  bread 
toasted,  announce  the  program  in  the  fewest  words.  Black  (rye) 
bread,  brown  bread,  baked  beans,  sourkrout,  cabbage,  mushrooms,  po- 
tato salad,  and  pickles  had  best  be  avoided.  Beverages  should  be 
limited  to  three  pints  daily,  and  may  consist  of  milk  or  water,  of  which 
not  more  than  a  glass  should  be  taken  at  a  time,  and  preferably  not  at 
meal  times,  but  between  them,  so  that  the  weakened  musculature  shall 
not  be  overstrained.  Our  best  results  have  always  been  obtained  when 
no  fluid  at  all  was  taken  at  meal  time,  but  at  least  thirty  minutes  were 
allowed  to  elapse  before  drinking.  Very  often  a  compromise  can  be 
made  with  patients  by  which  they  defer  the  use  of  beverages  until  the 
act  of  eating  is  completed.  Alcohol,  according  to  Klemperer,  improves 
the  motility,  and  a  little  wine  may  be  taken,  provided  hypersecretion 
does  not  accompany  the  lack  of  motility.  Beer  is  much  more  objection- 
able on  account  of  its  volume,  and  for  the  same  reason  soup  is  worse 
than  useless  because  the  amount  of  nourishment  derived  is  not  com- 
mensurate with  its  volume.  As  it  is  a  well-established  belief  that  the 
stomach  empties  more  rapidly  when  its  possessor  is  lying  on  the  right 
side,  this  is  usually  recommended  for  thirty  minutes  after  meals,  but, 
as  these  patients  are  rarely  bedridden  and  often  engaged  actively  in 
their  occupations,  it  is  difficult  to  carry  out  except  after  the  evening 
meal,  which  among  many  is  the  most  substantial  one  of  the  day.  Our 
belief  is,  if  the  patient  is  weary  or  agitated,  a  short  rest  on  a  couch 
before  the  meal  is  more  effective.     When  possible,  actual  forced  feed- 


386  DISEASES   OP    THE   DIGESTIVE   TRACT 

ing  should  be  attempted,  with  the  first  two  meals  in  bed,  after  which 
the  patient  may  arise  and  indulge  in  moderate  exercise,  but  not  directly 
after  a  hearty  meal,  and  bed  should  be  sought  early.  If,  however,  the 
patient  remains  in  bed  all  of  the  time,  appetite  will  flag,  constipation 
is  exaggerated,  and  the  individual  becomes  still  more  nervous.  In  ar- 
ranging a  diet,  attention  must  be  paid  to  the  character  of  the  gastric 
secretion  (increased  or  diminished)  and  the  condition  of  the  bowels. 
Where  the  patient  can  give  up  his  occupation,  the  diet  list  given  for 
malnutrition  (page  225)  works  admirably;  when  not,  and  constipation 
exists,  the  following  is  advantageous : 

DIET   LIST   IN   GASTRIC   ATONY   WITH    CONSTIPATION. 

On  rising. — A  glass  of  cold  water  with  a  tablespoonful  of  milk  sugar 
dissolved  in  it. 

Breakfast. — Orange,  apple,  grapefruit,  or  grapes,  or  any  kind  of 
cooked  fruit;  salt  codfish  in  cream,  or  finnanhaddie,  or  salt  mackerel, 
or  crisp  bacon,  with  a  baked  potato  and  abundant  butter;  some  toast 
or  rolls,  with  abundant  crust,  or  French  bread,  and  some  marmalade, 
jelly,  or  honey ;  small  cup  coffee. 

Midforenoon. — A  glass  of  buttermilk  or  tablespoonful  of  milk  sugar 
in  a  glass  of  water. 

Dinner. — No  soup,  three  heaping  tablespoonfuls  of  minced  lean  meat 
or  fish,  mashed  vegetables  (potato,  squash,  spinach,  young  pease,  or 
cauliflower)  ;  some  stewed  or  canned  fruit  without  seeds,  or  a  light 
pudding  (rice,  tapioca,  or  sago),  with  a  sauce  containing  fruit  juice 
(lemon,  orange,  or  berry  juice  from  canned  fruit)  ;  rolls  and  butter. 

Midafternoon. — Same  as  forenoon. 

Supper. — Scrambled  eggs,  fish  hash,  cornbeef  hash,  sardines,  soft 
cheese  (Brie,  Camembert,  or  cream)  ;  rolls  and  butter  and  some  cooked 
fruit;  weak  tea  if  desired. 

Bedtime. — A  tablespoonful  of  milk  sugar  in  a  glass  of  water. 

The  dinner  and  supper  can  be  interchanged  if  desired.  Nothing 
should  be  drunk  until  the  meal  is  ended,  and  great  care  should  be  taken 
to  eat  slowly. 

As  the  stomach  becomes  accustomed  to  take  up  its  increased  burden, 
the  amount  taken  can  be  increased  imperceptibly.  A  half  pint  of 
middle  heavj^  cream  can  be  added,  to  be  taken  on  baked  potato,  added 
to  the  buttermilk  and  poured  into  the  tea  and  coffee  generously,  or 
eaten  on  the  fruit.  Butter  can  be  added  in  large  quantities  to  the 
mashed  vegetables.  In  the  meantime  the  feelings  of  the  patient  are 
not  to  be  your  guide,  but  his  weight,  and,  if  this  steadily  increases, 


NERVOUS  DYSPEPSIA    (GASTRIC   NEUROSIS)  387 

success  is  assuredly  in  sight.  As  to  hydrotherapeutic  measures,  our 
experience  has  been  that,  if  continuous  secretion  does  not  exist  with 
the  atony,  lavage  is  worse  than  useless,  but  the  cold  spray  over  the  epi- 
gastrium or  even  the  plunge  works  extremely  well.  In  the  poorer 
practice,  where  a  spray  is  not  available,  dashing  cold  water  upon  the 
abdomen  as  on  the  face  makes  a  fairly  good  substitute.  All  of  these 
procedures  seem  to  strengthen  the  muscles  of  the  stomach,  so  that  the 
residue  six  to  seven  hours  after  a  Riegel  meal  grows  less  and  less.  The 
faradic  current  from  a  good  transformer  also  aids;  whether  by  sug- 
gestion or  by  actually  increasing  the  muscular  contractions  cannot  be 
told.  The  external  application  works  just  as  well  as  the  intragastric 
of  E  inborn  and  is  much  more  convenient. 

Massage  has  been  found  particularly  valuable  in  this  disease  of  the 
stomach;  whether  by  increasing  nutrition  or  by  actually  stimulating 
the  peristalsis  cannot  be  stated  positively.  It  seems  to  make  no  differ- 
ence whether  we  employ  the  manual  or  mechanical  variety,  and  the 
small  Johansen  instrument,  described  under  Treatment,  can  be  made 
to  do  all  that  is  required.  The  use  of  mineral  waters  has  no  place  in 
the  treatment  of  this  condition ;  in  fact,  has  never  failed  in  our  expe- 
rience to  make  the  failing  motility  worse.  Of  medicaments  which  will 
benefit  it  we  have  none  that  have  proven  their  worth.  There  are 
many,  however,  that  can  be  employed  and  are  recommended  by  differ- 
ent authorities.  Orexin  tannate  (if  no  hypersecretion  exists),  resor- 
cinol,  ereasote,  and  nux  vomica  can  be  used,  but  to  us  they  have  all 
seemed  futile  without  the  hydromechanical  therapy  and  the  diet. 
Sadly  must  it  be  acknowledged  that,  like  the  shotgun  therapy  of  old, 
it  is  difficult  to  say  which  of  these  agencies  is  the  most  effective,  but 
the  disease  is  so  obstinate  that,  with  all  your  means  of  attack — foot, 
horse,  and  artillery — one  can  make  but  slight  impression  on  it  after  a 
long  siege,  during  which  the  patient,  wearying  of  the  treatment,  often 
seeks  another  physician.  It  will  be  found  necessary  at  times  to  try  to 
overcome  the  pressure  and  discomfort  after  eating  in  order  to  induce 
the  patient  to  continue  the  hypernutrition  mode  of  treatment,  the  only 
effective  one  known  to  the  author,  and  validol  and  anesthesin,  already 
mentioned,  will  be  of  great  aid  in  rendering  the  stomach  more  tolerant 
of  its  burden.  The  constipation  w^hich  almost  invariably  accompanies 
gastric  atony,  and  may  be  due  to  an  associated  atony  of  the  intestine, 
must  not  be  treated  by  strong  laxatives,  which  invariably  increase  the 
failing  motility  of  the  stomach.  At  best,  only  the  milder  articles,  like 
agar-agar  and  petroleum,  may  be  used,  while  our  chief  dependence  is 
placed  on  diet  and  enemata. 


388  DISEASES  OP   THE   DIGESTIVE   TRACT 

Insufficiency. — Insufficiency  or  relaxation  of  the  cardia,  though  often 
a  symptom  of  nervous  dyspepsia,  may  be  the  sole  symptom,  and  rarely 
deserves  consideration  under  those  circumstances  as  an  entity.  AVhile 
the  cardia  should  normally  close  against  the  peristaltic  action  of  the 
stomach  allowing  perhaps  only  gases  to  escape,  it  often  permits  the 
food  to  rise  into  the  esophagus  or  mouth,  where  it  may  be  ejected  (re- 
gurgitation) or  swallowed  (rumination).  The  peculiarity  of  both  is 
its  early  onset — at  once  after  the  meal  is  eaten,  say  the  patients — and 
the  food  tastes  as  when  sw-allowed,  not  sour  or  bitter,  as  later  in  the 
digestion  when  stenosis  of  the  pylorus  is  present.  As  the  cardia  is  in- 
nervated by  a  branch  of  the  vagus  (N.  dilator  cardias),  an  undue 
stimulation  of  this  nerve  leaves  the  sphincter  open.  This  stimulation 
of  the  vagus — vagotonus,  as  it  is  called — ^may  be  of  central,  peripheral, 
or  reflex  origin,  and  is  found  in  marked  hysteria,  neurasthenia,  or 
idiocy.  The  patient  often  complains  of  vomiting,  but  on  closer  ques- 
tioning it  is  found  that  only  a  mouthful  is  brought  up  at  a  time,  and 
no  emaciation  follows  as  in  persistent  vomiting.  Another  peculiarity 
is  that  no  nausea  accompanies  it.  Furthermore,  it  may  be  voluntary, 
and  some  individuals,  when  discomfort  is  felt,  have  the  power  of  volun- 
tarily relieving  the  stomach  by  this  act.  Not  long  ago  a  patient  in- 
formed us  that  the  passage  of  the  stomach  tube  would  not  be  neces- 
sary, as,  with  a  swallow  or  two  of  water,  she  could  bring  up  the  test 
breakfast,  which  she  promptly  did  in  our  presence  an  hour  after  it 
was  taken,  and  assured  us  that  she  often  did  this  for  relief.  Further 
examination,  including  a  radiogram,  showed  that  she  had  a  chronic 
gastric  ulcer.  In  other  cases  under  our  observation  no  change  in 
the  gastric  contents  was  observed,  though  a  flow  around  the  tube,  when 
withdrawing  them,  clinched  the  diagnosis. 

Treatment. — The  treatment  is  very  unsatisfactory,  but  something 
may  be  accomplished  by  intraventricular  faradization,  and  one  case 
was  cured  by  forbidding  the  patient  to  remain  alone  and,  in  the  pres- 
ence of  another,  shame  prevented  her  from  committing  the  act,  which 
was  semivoluntary. 

Insufficient  or  relaxed  pylorus,  another  symptom  dignified  to  a  dis- 
ease, is  largely  based  on  the  evidence  of  inability  to  inflate  the  stomach 
by  air  or  the  effervescent  mixture,  as  well  as  the  presence  of  bile  and 
pancreatic  juice  in  the  gastric  contents  after  the  stomach  has  been 
washed  out  and  the  test  breakfast  given,  for  the  duodenal  secretions 
evidently  come  through  the  pylorus  freely  during  fasting.  The  cause 
is  usually  an  old  ulcer  scar  at  the  pylorus  preventing  complete  closure, 
but  not  sufficiently  extensive  to  produce  stenosis.     The  nervous  variety 


NERVOUS  DYSPEPSIA    (GASTRIC   NEUROSIS)  389 

has  never  come  under  our  observation,  and  some  skepticism  is  permis- 
sible as  to  its  existence. 

The  treatment  is  wholly  futile,  and,  as  no  discomfort  or  harm  is 
caused  by  it,  unless  a  supposed  diarrhea,  which  is  more  often  due  to  a 
concomitant  aehylia,  its  management  is  that  of  the  accompanying  ulcer 
or  absent  gastric  juice. 

SENSORY  DISTURBANCES. 

Sensory  disturbances  of  the  stomach  may  be  either  purely  neuroses 
or  a  symptom  accompanying  other  gastric  diseases. 

Bulimia. — Bulimia,  so-called,  is  a  desire  for  food,  imperative  and  be- 
yond the  needs  of  the  organism.  It  may  be  well  regarded  as  an  exag- 
gerated sense  of  hunger,  and  is  accompanied  by  the  most  unpleasant 
sense  of  discomfort  unless  food  can  be  promptly  obtained.  A  small 
quantity,  such  as  a  glass  of  milk  or  a  couple  of  crackers,  are  often  suf- 
ficient to  stay  this  hunger.  Attacks  often  come  on  in  the  middle  of 
the  night,  and  sleep  is  sought  in  vain  until  the  food  is  obtained. 

Symptoms. — The  symptoms  are  both  local  and  general.  The  former 
consists  of  a  feeling  of  emptiness  in  the  epigastrium,  that  may  in- 
crease to  actual  pain.  The  latter  consists  of  headache,  roaring  in 
the  ears,  vertigo,  trembling,  and  actual  fainting  may  occur;  the  face 
may  be  pale  and  the  extremities  cold.  Such  a  condition  is  not  con- 
stant, but  comes  in  paroxysms,  sometimes  being  the  outcome  of  nerv- 
ous excitation,  while  these  attacks,  when  intermittent,  are  usually  as- 
sociated with  neurasthenia.  When  the  condition  is  persistent,  it  is  a 
symptom  of  some  general  disease  like  diabetes,  general  paralysis,  early 
dementia,  and  Basedow's  disease,  or  of  a  localized  disease  like  gastric 
hypersecretion  or  ulcer,  tapeworm,  diarrheas,  and  gastric  ectasia.  An 
access  just  before  death  in  chronic  disease  is  a  popular  belief  among 
the  laity,  and  one  instance  has  come  under  our  observation  where  a 
man  dying  of  cardiorenal  disease,  enormously  edematous,  demanded 
and  obtained  from  his  attendants  a  hearty  meal  two  hours  before  his 
death. 

Treatment. — The  treatment  must  be  devoted,  first,  to  the  control 
of  the  underlying  cause,  and,  second,  to  dulling  the  sensation  at  the 
time  of  the  paroxysm.  If  associated  w^ith  hj^persecretion  or  ulcer,  the 
dietary  and  medicinal  treatment  of  these  diseases  suggest  themselves. 
If  with  neurasthenia,  the  most  common  accompaniment,  the  bromides 
in  gram  doses  hold  it  in  control  until  hydrotherapy,  electricity,  mas- 
sage, etc.,  can  be  employed.     When  attacks  occur  at  night,  a  supposi- 


390  DISEASES  OP  THE  DIGESTIVE  TRACT 

tory  of  extractum  belladonnas  and  extractum  opii  aa  0.030  gram  (Y^ 
grain)  inserted  at  bedtime  will  often  ward  off  an  attack.  Closely  allied 
with  this  condition  is  the  lack  of  sense  of  gratification  of  hunger,  as 
many  say,  ' '  I  rise  from  the  table  as  hungry  as  I  sat  down. ' '  This  pe- 
culiarity, too,  may  be  associated  with  some  disease  like  diabetes  or  obes- 
ity, or  may  be  one  of  the  manifestations  of  neurasthenia.  In  the  latter 
case,  in  spite  of  the  enormous  quantities  of  food  taken,  containing 
far  more  calories  than  the  weight  of  the  individual  demands,  the  pa- 
tient is  always  thin  and  apparently  undernourished.  As  freaks  these 
individuals  often  appear  in  museums,  and  are  reported  in  ne^vspapers 
as  indulging  in  strange  wagers,  where  innumerable  eggs,  oysters,  pies, 
etc.,  are  eaten  without  apparent  injury  and  with  the  statement  that  the 
appetite  was  still  unappeased. 

Nervous  Anorexia. — Nervous  anorexia  is  characterized  by  an  utter 
distaste  for  food,  whose  sight  and  odor  often  arouse  nausea.  The  in- 
fluence of  appetite  on  the  gastric  secretion  has  already  been  mentioned, 
and  we  are  all  aware  how  quickly  disappointment,  grief,  or  sudden 
fright  will  take  away  appetite  temporarily,  and,  if  food  be  taken  at 
that  time,  what  discomfort  follows  its  digestion.  The  anorexia,  how- 
ever, of  which  we  speak  now  is  chronic,  and,  in  spite  of  its  existence, 
the  patients,  as  far  as  can  be  learned  from  gastric  analyses,  have  a  per- 
fect digestion.  Our  first  effort  must  be  to  exclude  any  organic  disease 
like  gastric  achylia  or  cancer  and  gastritis,  which  have  often  appeared 
to  us  to  be  particularly  provocative  of  distaste  for  food.  Early  pul- 
monary tuberculosis  is  also  noted  for  this  peculiarity,  and  the  struggle 
to  induce  many  of  these  sufferers  to  participate  in  the  newer  treatment 
of  hypernutrition  is  common  to  all  physicians.  As  a  purely  functional 
disorder,  it  is  most  frequent  among  young  girls,  and,  unless  they  eat 
surreptitiously,  it  is  astonishing  sometimes  to  note  with  what  a  small 
quantity  of  food  they  can  keep  their  weight  and  general  air  of  well- 
being.  This  condition  is  popularly  supposed  to  be  associated  with 
love,  requited  or  unrequited,  so  that  among  the  laity,  whose  observa- 
tions are  worthy  of  some  credence,  exultation  or  depression  are  equally 
provocative.  From  mental  abstraction  men,  bent  on  some  discovery  or 
putting  through  a  ''deal,"  as  it  is  called,  often  suffer  from  a  form  of 
anorexia,  and  will  state  that,  without  being  reminded,  they  would 
never  think  of  eating  and  cannot  state  whether  they  have  eaten  or  not. 
As  Lasegue  has  expressed  it,  the  victim  of  gastric  disease  without  appe- 
tite is  distressed  that  he  cannot  eat,  w^hile  to  one  suffering  from  nerv- 
ous anorexia  it  is  a  matter  of  utter  indifference  whether  he  eats  or 
not.    Naturally,  the  outcome  of  this  distaste  for  food  is,  after  a  time. 


NERVOUS   DYSPEPSIA    (GASTRIC   NEUROSIS)  391 

diminished  secretion  of  gastric  juice  and  an  uncomfortable  period  of 
digestion,  which  to  the  young  girl  is  a  still  stronger  argument  in  favor 
of  going  without  food.  Fatal  cases  have  never  come  under  our  ob- 
servation, but  Bouveret  reports  several  from  pure  inanition. 

Treatment. — The  treatment  is  both  dietetic  and  rational.  If  no  or- 
ganic disease  can  be  discovered,  the  patient,  who  will  often  partake  of 
highly  seasoned  articles,  should  always  have,  as  an  introduction  to  a 
meal,  a  cup  of  bouillon,  a  caviar  sandwich,  or  an  anchovy  salad  for  the 
desire  for  such  articles  is  often  very  marked.  These  preliminary 
courses  should  be  in  small  quantity  and  tastily  arranged,  when  often 
other  articles  of  food  will  be  taken  afterward  with  relish.  If  these 
means  are  not  sufficient,  the  patient  should  be  removed  from  the  family 
circle  and  placed  in  a  sanitarium,  where  food  should  be  brought  at  regu- 
lar intervals  in  the  most  attractive  form,  always  garnished  with  parsley 
or  cherries.  In  addition  to  the  diet,  the  hydrotherapeutic,  massage,  and 
electricity  facilities  of  the  sanitarium  will  be  called  on  sometimes  in 
vain  to  effect  a  cure.  Very  often  the  introduction  of  food  by  the  tube, 
or  even  a  declaration  of  intention  to  perform  this  act,  will  induce 
the  patient  to  attempt  to  eat.  Sometimes  this  will  often  remove  the 
fear  of  strangling,  which  some  patients  have  from  the  presence  of  the 
globus  hystericus.  The  usual  bitters,  orexin,  nux  vomica,  and  con- 
durango  may  be  employed,  but  one  need  not  expect  much  from  their 
use. 

Nausea. — Xausea  is  common  enough  as  a  symptom  of  actual  gastric 
disease,  but  there  is  also  a  nausea  of  purely  nervous  origin,  which 
may  be  a  part  of  hysteria  or  neurasthenia,  or  exist  as  the  sole  symp- 
tom. ]Many  times  it  comes  on  only  at  the  sight  of  food,  but  may  occur 
at  other  periods,  as  in  the  early  morning  or  during  the  night.  The 
feeling  may  arouse  a  few  ineffectual  attempts  at  vomiting,  or  may 
continue  until  a  little  mucus  and  bile  are  evacuated  when  the  attack  is 
over.  This  nervous  nausea  is  most  common  among  women,  and  is  due 
to  some  mechanical  displacement  of  the  uterus  or  to  early  pregnancy. 
One  of  the  most  obstinate  cases  in  our  experience  was  that  of  a  young 
surgeon,  in  whom  no  other  anomaly  could  be  found  than  an  absence  of 
hydrochloric  acid  from  the  gastric  contents,  and  both  conditions  were 
undoubtedly  of  nervous  origin. 

Treatment.— The  treatment  consists  of  improving  the  nutrition  of 
the  patient,  and,  when  the  attack  comes  on  early  in  the  morning,  it  is 
best  for  the  sufferer  to  take  breakfast  in  bed  and  then  allow  a  short 
time  to  elapse  before  attempting  to  rise.  This  advice  works  equally 
well  in  those  prone  to  seasickness,  and  our  personal  experience  is  that 


392  DISEASES   OF   THE   DIGESTIVE   TRACT 

the  most  trying  hours  of  a  stormy  voyage  are  those  from  rising  time  to 
breakfast.  Validol  and  anesthesin  have  both  served  us  in  keeping  this 
curious  anomaly  in  cheek. 

Nervous  Cardialgia. — Nervous  cardialgia,  or  gastralgia,  is  a  term 
still  in  common  use  to  describe  paroxysmal  attacks  of  pain,  sudden  in 
their  occurrence,  beginning  in  the  epigastrium  and  radiating  to  the 
right  or  left  along  the  costal  borders  to  the  back.  Sometimes  it  is  prop- 
agated along  the  sternum,  and  is  described  as  a  burning  pain,  though 
no  increase  of  hydrochloric  acid  or  pyrosis  exists.  These  attacks  differ 
from  those  of  cardiospasm,  which  is  a  more  chronic  affair,-  in  that, 
when  a  tube  is  introduced  in  the  latter,  it  meets  with  temporary  ob- 
struction that  is  soon  overcome.  The  gastralgia,  however,  should  not 
be  taken  for  a  functional  disease  until  the  most  careful  search  has 
failed  to  find  an  organic  source  for  the  attacks,  and  many  deny  the  ex- 
istence of  the  purely  nervous  form  of  gastralgia.  Cohnheim,  among 
these,  gives  the  following  causes  for  these  attacks  of  stomach  cramps, 
and  thinks  that  all  instances  may  be  brought  under  these  groups : 

1.  Diseases  of  the  stomach  itself  (ulcer,  spasm  of  the  pylorus,  hyper- 
secretion, perigastritis,  and  carcinoma). 

2.  Diseases  of  neighboring  organs  (cholelithiasis,  pancreatic  colic, 
angina  pectoris,  and  hernia  linee  albae). 

3.  Diseases  of  the  central  nervous  system  (tabes  dorsalis — gastric 
crises — myelitis,  and  cerebral  tumor). 

4.  Intoxications  (malaria  and  misuse  of  tobacco). 

5.  Reflex  disturbances  from  the  genitourinary  organs  (abnormali- 
ties of  menstruation,  the  climacteric,  retroflexion  of  the  uterus,  and 
hypertrophied  prostate). 

On  physical  examination  we  often  find  the  victims  to  be  excitable, 
badly  nourished,  with  gastroptosis,  pulsating  sensitive  abdominal 
aortas,  with  a  tender  celiac  plexus,  and  often  the  whole  of  the  epigas- 
trium is  hypersensitive.  It  is  rare  that  one  of  these  various  stigmata 
cannot  be  found  to  account  for  the  periodic  attacks  of  pain,  and  it  is 
only  after  the  most  careful  examination  that  we  should  content  our- 
selves with  the  diagnosis  of  nervous  gastralgia.  Anemia  and  chlorosis, 
particularly  in  girls  at  or  before  puberty,  are  unquestioned  causes  of 
these  stomach  cramps,  the  attacks  lasting  from  twenty  to  forty  min- 
utes. Between  the  spasms  no  discomfort  is  experienced,  and  examina- 
tion of  the  gastric  contents  shows  usually  nothing  abnormal.  Such 
cases  improve  much  more  on  the  use  of  iron  than  on  the  various  anti- 
spasmodics and  means  employed  toward  improving  the  digestion,  which 
is  in  itself  a  proof  of  the  hematic  origin  of  the  illness.     The  small  epi- 


NERVOUS  DYSPEPSIA    (GASTRIC   NEUROSIS)  393 

gastric  hernias  are  also  undoubtedly  provocative  of  these  attacks  of 
pain,  and,  when  present,  should  be  either  reduced  and  held  in  posi- 
tion or  removed  surgically,  as  such  means  have  caused  the  attacks  of 
pain  to  cease.  Attention  has  already  been  called  to  the  arteriosclero- 
sis of  the  abdominal  arteries  as  a  cause  for  pain,  often  mistaken  for 
gastralgia,  occurring  at  night,  without  reference  to  food,  and  more 
often  after  a  strenuous  day.  There  may  be  an  associated  meteorism 
and  irregular  movements  of  the  bowels,  an  increased  blood  pressure, 
and  evidences  of  sclerosis  in  the  superficial  arteries,  or  the  secondary 
involvement  of  the  heart  (hypertrophy)  usually  establishes  the  diag- 
nosis. 

Treatment. — The  treatment  seeks  to  accomplish  two  purposes — re- 
lieve the  attack  of  pain  and  prevent  its  reoccurrence.  The  first  pur- 
pose can  be  best  accomplished  by  a  hypodermic  of  morphine  sulphate, 
employing  0.015  gram  (I/4  grain)  and  watching  results.  If  no  relief 
is  obtained,  a  second  injection  of  an  equal  amount  should  follow  in  ten 
to  twenty  minutes.  Morphine  should  never  be  given  the  patient  to 
take  by  the  mouth,  for,  if  the  attacks  are  common,  as  they  are  apt  to 
be,  the  morphine  habit  is  soon  acquired.  Chloroform,  as  chloroform 
water,  in  tablespoonful  doses  or  2-5  drops  of  the  former  on  ice  pellets, 
codeine  sulphate  in  0.03-gram  (Yo-grsim)  doses,  and  cocaine  hydrochlo- 
ride in  similar  doses  have  been  used  by  us  per  oram,  frequently  during 
an  attack  to  avoid  the  use  of  morphine,  but  it  is  usually  in  vain,  and  one 
must  have  recourse  to  the  hypodermic.  To  prevent  the  recurrence,  we 
must  treat  the  underlying  condition.  If  cholecystitis,  the  gallbladder 
must  be  drained,  for,  while  many  recover  spontaneously,  it  is  only  after 
a  long  and  tedious  illness,  with  much  discomfort  and  the  constant  dan- 
ger of  morphinism ;  if  from  anemia,  iron  in  the  form  of  ferrum  oxidura 
saecharatum  in  doses  of  0.3  gram  (5  grains)  several  times  daily  should 
be  employed,  or  Fowler's  solution,  well  diluted,  often  acts  like  a 
charm,  accompanied  by  appropriate  diet;  if  dependent  on  tabes,  chro- 
mium sulphate  in  doses  of  0.25-0.5  gram  (4—8  grains)  will  sometimes 
aid,  but  these  cases,  all  must  acknowledge,  are  the  most  hopeless  as  re- 
gards treatment ;  if  due  to  abdominal  arteriosclerosis,  diuretin  in 
1.0-gram  (15-grain)  doses  two  to  three  times  daily,  or  sajodin  in  doses 
of  0.5  gram  (8  grains),  will  soon  relieve  the  symptoms;  if  resulting 
from  an  epigastric  (fatty)  hernia,  the  application  of  some  adhesive 
plaster,  with  a  well-covered  button  or  coin  underneath  and  over  the 
protrusion,  will  often  relieve  it.  Uterine  malpositions,  partial  atresia 
of  the  cervical  canal,  etc.,  should  be  referred  at  once  to  a  gynecologist, 
whose  correction  of  the  abnormality  will  often  check  immediately  any 


394  DISEASES   OF   THE   DIGESTIVE   TRACT 

further  attacks  of  gastric  pain.  Then,  there  remain  the  numerous 
purely  neurasthenics,  who  only  after  a  long  employment  of  every  fa- 
cility in  the  way  of  dietetic  and  hygienic  treatment — commonly  known 
as  the  "building-up"  process — can  be  helped,  and  then  often  to  a  very 
limited  extent.  They  form  the  class  wJio  wander  from  physician  to 
physician  without  relief,  finally  eschew  doctors  and  take  to  Christian 
science. 


PART  III 
SPECIAL  INTESTINAL  DISEASES 


CHAPTER  XV 

FUNCTIONAL  DISTURBANCES  OF  INTESTINAL  DIGESTION 
(INTESTINAL  INDIGESTION) 

This  term  implies  any  departure  from  the  normal  functions  of  the 
intestinal  canal,  but  in  such  a  sense  it  can  represent  not  only  a  disease, 
but  a  symptom,  for  any  pathologic  change  in  the  canal — be  it  inflam- 
matory, a  stenosis,  or  a  new  growth — must  of  necessity  produce  one  or 
more  changes  in  its  secretory,  motile,  absorptive,  or  excretive  func- 
tions. Still,  there  are  many  functional  diseases  which  are  not  depend- 
ent on  any  anatomical  change  in  the  gut,  but  on  anomalies  in  the  se- 
cretion of  other  organs — the  gastric  juice,  bile,  and  pancreatic  juice. 
Therefore,  while  the  deprivation  of  the  intestine  of  the  whole  or  a  part 
of  these  powerful  digestive  aids,  leading  to  secondary  inflammatory 
changes  and  actual  anatomical  modifications,  may  produce  the  same 
effects,  yet  the  symptoms  so  overshadow  any  anatomical  changes  which 
can  be  found  that  we  may  look  on  them  as  an  entity  in  disease.  Many 
times  we  have  instances,  especially  in  children,  where  the  most  care- 
ful examination  does  not  allow  us  to  make  any  other  diagnosis  than 
intestinal  indigestion,  though  we  are  well  aware  that  we  are  taking 
the  shadow  for  the  object  which  we  cannot  discern.  Hence  the  use  of 
the  terms  nervous  diarrhea  and  intestinal  indigestion  has  remained 
the  prerogative  of  physicians,  though  few  have  any  idea  of  their  na- 
ture beyond  the  fact  that  they  represent  frequent  movements  without 
mucus  and  general  discomfort  below  the  belt  line. 

ACUTE  INTESTINAL  INDIGESTION. 

Acute  intestinal  indigestion  is  not  an  uncommon  condition,  charac- 
terized by  thin,  watery  discharges  containing  neither  mucus,  blood, 
nor  pus;  in  fact,  those  abnormal  factors  which  indicate  a  true  inflam- 
matory change.  The  duration  is  so  short,  and  so  seldom  is  it  danger- 
ous to  life,  that  we  have  never  been  able  to  discover  whether  any  patho- 
logic change  underlies  it.  The  examination  of  the  feces,  which  alone 
can  give  us  any  information  of  the  abnormality  of  the  tract,  simply  in- 

397 


398  DISEASES   OP   THE   DIGESTIVE   TRACT 

dicates  that  there  must  be  an  enormous  transudation  into  the  intestine. 
Even  this  is  not  always  demonstrable,  for  the  stool  may  be  only  mushy, 
and  then  our  simple  evidence  is  the  presence  of  numerous  food  frag- 
ments and  their  decomposed  products  (gases  from  carbohydrates,  etc.). 
Clinically,  these  attacks  evince  themselves — after  the  ingestion  of  cer- 
•  tain  articles  of  food  or  drink,  which,  unassailable  in  purity  (milk, 
strawberries,  etc.),  affect  individual  patients  unfavorably  as  an  idio- 
syncrasy, or  such  as  are  partially  decomposed,  or  at  least  not  strictly 
fresh — in  colicky  abdominal  pains,  frequent  stools,  and  rectal  tenes- 
mus. After  a  short  period  of  abdominal  discomfort,  often  accompa- 
nied by  loud  gurgling  noises,  the  patient  must  seek  the  water-closet, 
where,  after  the  passage  of  a  solid  or  semisolid  stool,  relief  is  tempora- 
rily obtained,  but  the  same  cycle  is  soon  repeated,  and  now  come  fre- 
quent fluid  dejections,  with  much  gas.  According  to  the  severity  of 
the  attack,  this  may  cease  on  the  first  day  or  may  continue  into  the  next 
before  the  stool  again  becomes  normal.  Apart  from  a  sense  of  abdom- 
inal discomfort  and  the  initial  colicky  pains,  the  condition  of  the  pa- 
tient is  not  changed.  His  appetite  remains  the  same,  though  he,  wise 
from  previous  experience,  frequently  chooses  tea  and  toast  or  flour 
gruel  until  the  attack  is  over.  This  is  sometimes  accompanied  or  pre- 
ceded by  nausea  and  vomiting — a  typical  "summer  complaint,"  as  it 
is  often  termed — and  the  food  vomited  is  usually  that  which  has  been 
eaten  six  to  eight  hours  before,  a  true  sign  of  the  sympathetic  or  initial 
involvement  of  the  stomach.  In  this  case  the  tongue  is  coated,  the  ap- 
petite fails,  there  is  a  bad  odor  of  the  breath,  and  there  may  be  eructa- 
tions. "When,  as  often  happens,  the  vomiting  occurs  first,  several  hours 
may  elapse  after  it  ceases  before  the  diarrhea  begins.  The  physician 
is  rarely  summoned  until  after  the  illness  has  lasted  some  time,  and 
then  the  examination  of  feces  offers  but  little  light,  but  observing  pa- 
tients often  declare  that  the  discharges  w^ere  dark,  with  a  putrid  odor, 
or  light-colored,  sour  smelling,  and  frothy.  An  earlier  inspection  by 
the  physician  would  probably  show  that  they  do  not  differ  from  those 
of  chronic  intestinal  indigestion  and  possess  the  characteristics  of 
marked  protein  putrefaction  or  carbohydrate  fermentation.  In  fact, 
it  comes  to  the  attention  of  every  physician  that  the  chronic  form  is 
always  preceded  by  one  or  more  attacks  of  this  acute  variety,  the  last 
of  which  progresses  to  the  persistent  form. 

Treatment. — The  treatment  consists  of  an  initial  purge  by  castor 
oil  or  calomel  if  there  have  not  been  numerous  discharges,  and  then 
the  use  of  a  bland  diet  of  milk,  gruel,  broth,  toast,  and  gelatine.  Also 
the  following  mixture  will  be  found  beneficial: 


FUNCTIONAL  DISTURBANCES   OF   INTESTINAL  DIGESTION  399 

IJ     Bismuthi   subgallatis    6.0  or  li/4  drams 

Misturae  cretae 100.0  or  3  ounces 

M.  Sig. :     Teaspoonful  every  three  hours.     Shake  Avell. 

CHRONIC  GASTROGENOUS  INTESTINAL  INDIGESTION. 

Chronic  gastrogenous  intestinal  indigestion  has  become  pretty  well 
recognized  by  its  recurrent  type,  in  which  intervals  of  comparative 
well-being  are  interspersed  when  the  stools  are  normal  in  consistency 
and  number,  or  the  diarrhea  may  be  constant.  Furthermore,  an  in- 
vestigation of  the  gastric  functions  usually  shows  a  deficiency  of  gas- 
tric juice,  particularly  of  hydrochloric  acid,  even  if  a  complete  achylia 
does  not  exist.  This  constant  relation  between  the  disturbed  gastric 
and  intestinal  digestion  has  further  been  proven  by  the  fact  that,  with 
a  largely  meat-free  diet  and  the  medicinal  use  of  hydrochloric  acid,  the 
diarrhea  can  be  kept  under  control.  Nor  need  it  be  always  the  secre- 
tory function  of  the  stomach  which  is  disturbed,  for  impairment  of 
gastric  motility  may  also  be  a  causative  factor  in  the  maintenance  of 
the  diarrhea.  So  far  has  A.  Schmidt  carried  this  observation  that  the 
presence  in  the  stool  of  large  quantities  of  connective  tissue  would  be 
regarded  by  him  as  proof  positive  of  a  failing  secretion  and  motility  of 
the  stomach.  Our  own  observations,  published  in  an  article  previously 
mentioned  (page  164),  would  not  allow  us  to  go  as  far  as  that,  but, 
when  this  peculiarity  of  the  stool  is  found,  gastric  examination  rarely 
fails  to  show  lacking  stomach  functions.  The  explanation  of  this 
diarrhea  has  been  offered  in  the  loss  of  the  bactericide  action  of  hydro- 
chloric acid,  which  has  long  ago  been  refuted  by  the  author  and  others, 
in  the  impairment  of  the  amount  of  pancreatic  juice,  which  almost  in- 
variably accompanies  it,  and  in  the  increasing  residue  of  meat  fibers 
in  the  intestine,  an  admirable  culture  medium  for  putrefactive  bacteria, 
due  to  the  failure  of  digestion  of  the  connective  tissue  which  incloses 
the  fiber  and  fat,  and  hence  restrains  them  from  the  action  of  the  pan- 
creatic juice. 

Symptoms. — The  symptoms  usually  begin  with  those  pertaining  to 
the  stomach — loss  of  appetite,  nausea,  pressure  after  eating,  and  eruc- 
tations— but,  when  the  unpleasant  abdominal  sjTnptoms  begin,  the 
former  have  ceased,  or,  because  of  the  greater  prominence  of  the  lat- 
ter, are  forgotten.  The  stools  diminish  in  consistency  and  increase  in 
frequency;  in  fact,  form  what  is  commonly  known  as  diarrhea,  which 
either  accompanies  the  gastric  symptoms  or  follows  them  after  a  very 
short  interval.  The  first  attack  may  be  stayed  and  recurrent  ones  ap- 
pear until  the  disease  is  chronic,  or  the  first  one  may  persist  without 


400  DISEASES   OP    THE   DIGESTIVE   TRACT 

any  relief.  Sometimes,  indeed,  the  initial  gastric  symptoms  have  en- 
tirely disappeared,  and  the  patient  does  not  come  to  the  physician 
until  the  diarrhea  has  become  unendurable,  being  frequently  of  five  to 
ten  years'  duration.  Sometimes  this  diarrhea  may  be  the  outcome  of 
a  typhoid  fever,  and  perhaps  more  often  the  result  of  an  infantile  in- 
testinal catarrh.  Almost  always  the  disease,  when  first  observed,  is 
chronic,  as  evinced  by  the  absence  of  colicky  pains  and  the  presence  of 
malnutrition.  Still,  after  long  duration  we  may  observe  a  moderate 
loss  of  flesh,  weakness,  and  anemia,  particularly  when  no  long  inter- 
vals have  intervened  between  the  attacks  of  diarrhea.  Very  often  pa- 
tients complain  that  certain  articles  of  diet  like  ice  cream,  game,  or  ice 
water  bring  on  an  attack,  or  that  sudden  cooling  of  the  body,  as  in 
marked  change  in  temperature,  riding  in  an  open  car  when  heated,  etc., 
is  the  cause.  They  describe  themselves  as  the  victim  of  a  "weakness" 
of  the  bowels  as  they  would  a  tendency  to  colds  or  rheumatism.  Nor 
need  this  frequency  be  a  typical  diarrhea  distributed  over  the  day. 
Many  are  aroused  in  the  early  morning,  have  one,  two,  or  more  loose 
movements,  and  then  are  not  troubled  for  the  day,  or  some  have  to 
leave  every  meal,  or  only  dinner,  for  stool  and  then  can  finish  the  day 
in  comfort.  Periods,  too,  of  confined  bowels  may  intervene,  but  even- 
tually the  diarrhea  always  returns.  The  disagreeable  odor  of  the 
stool  is  always  described,  and,  while  no  actual  pain  may  be  present, 
there  is  usually  more  or  less  distention  of  the  abdomen  and  unpleasant 
rumbling  of  the  intestines.  The  appetite  remains  excellent,  and  this 
alone  often  leads  the  patients  to  excesses.  AVhile  the  general  condition 
may  not  be  impaired,  it  is  usual  to  find  the  sufferers  with  thin  abdom- 
inal walls  and  a  peculiar  paleness,  dependent  on  the  frequent  reduction 
of  the  hemoglobin  to  75  per  cent  and  the  number  of  the  erythrocytes 
diminishes  to  3.5  millions.  The  gastric  analysis  usually  shows  the 
acidity  not  above  10  and  the  free  hydrochloric  acid  absent.  E.  Schuetz 
has  frequently  found  the  motility  impaired  even  with  the  presence 
of  hydrochloric  acid.  The  stools  are  noted  for  being  "mushy,"  or 
even  liquid,  but  no  mucus  can  be  found.  On  a  self-chosen  diet  the  pa- 
tient passes  many  fragments  of  undigested  vegetable  matter  (rem- 
nants of  celery,  lettuce,  pea  hulls,  etc.)  and  connective  tissue  visible 
to  the  naked  eye.  On  the  Schmidt  diet  these  often  disappear,  and 
diarrhea,  too,  may  cease,  or  there  may  be  only  two  soft  stools  daily. 
Again,  on  the  test  diet  the  diarrhea  may  increase,  which  is  probably 
due  to  the  large  quantity  of  milk  taken. 

]\Iicroseopically,  such  a  stool  will  show  many  a  muscle  fiber  with 
sharp  edges  and  well  colored,  together  with  starch  granules  inside  the 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL   DIGESTION  401 

potato  cells,  as  well  as  the  latter  without  the  granules;  neutral  fats 
and  fatty  acids  are  usually  wanting,  as,  on  the  whole,  fat  is  well  di- 
gested and  absorbed. 

The  question  naturally  arises  how  many  achylics,  or  those  suffering 
from  anacidity,  have  this  intestinal  indigestion.  E.  Schuetz,  taking 
statistics  from  reports  of  all  authors,  declares  that  30  per  cent  suffer 
from  temporary  or  persistent  diarrhea.  A  noticeable  factor  in  the 
characteristic  of  the  stool  is  the  absence  of  mucus,  for,  while  in  the 
gastric  contents  its  presence  is  not  of  so  great  import,  in  the  stool  it 
means  a  catarrh,  and  here  it  divides  the  purely  functional  intestinal 
indigestion  from  that  with  inflammatory  changes.  The  persistent 
presence  of  meat  fibers  and  starch  in  the  feces  points  also  to  a  lacking 
action  of  the  pancreatic  juice ;  not  necessarily  an  insufficient  amount 
of  the  juice,  but,  on  account  of  the  short  stay  of  the  food  in  the  duo- 
denum, due  to  the  increased  peristalsis,  the  food  fragments  are  less 
assailable  to  the  pancreatic  ferments.  Efforts  actually  made  to  deter- 
mine whether  the  pancreatic  juice  was  really  diminished,  as  estimated 
by  the  relative  weakness  of  the  action  of  trypsin  in  these  diarrheas, 
have  never  given  positive  results  either  one  way  or  the  other.  The 
facts  to  be  emphasized  in  this  disease  are,  largely,  that  it  is  confined 
to  the  small  intestine,  is  not  catarrhal  or  inflammatory,  and  damages 
chiefly  the  digestion  and  absorption,  now  of  protein,  now  of  starch,  and 
often  of  both. 

Treatment. — The  treatment  of  this  condition  is  preeminently  a  die- 
tetic one,  and,  on  account  of  the  primary  failure  of  the  stomach  to 
attack  the  envelope,  the  connective  tissue  of  meat  and  the  pectins,  the 
basis  of  the  vegetable  structure,  so  that  the  meat  fiber  and  starch  may 
be  subjective  to  the  digestive  action  of  the  ferments  of  the  pancreas, 
the  most  minute  division  of  the  food  is  absolutely  necessary.  "When, 
on  account  of  imperfect  teeth  or  the  habit  of  hasty  eating,  this  cannot 
be  accomplished  by  natural  means,  we  must  obtain  the  same  results 
by  artificial  aids.  All  meats  must  be  finely  chopped  or  ground  and 
vegetables  mashed,  to  which  must  be  added,  of  course,  thorough  cook- 
ing. As  the  deficiency  of  gastric  digestion  is  the  exciting  cause,  all 
those  precautions  given  under  gastric  achylia  and  hypochlorhydria 
must  be  observed,  and,  above  all,  care  must  be  taken  that  large  quan- 
tities of  food  are  not  taken  at  a  time.  AYhen  meat  fibers  or  starch 
predominate  in  the  stools,  we  may  restrict  the  one  or  the  other,  but, 
on  the  whole,  the  patient  should  receive  a  mixed  diet,  with  the  in- 
gredients in  the  usual  proportion.  Equally  suggestive  of  the  need  of 
restriction  of  the  protein  or  carbohydrates  is  the  putrid  odor  and 


402  DISEASES   OF   THE   DIGESTIVE   TRACT 

marked  alkaline  reaction,  or  the  sour  odor  and  strong  acid  reaction. 
It  is  sometimes  surprising  how  the  abstention  from  meat  or  vegetables, 
in  either  case,  will  cause  the  frequent  passages  to  be  limited  to  one  or 
two  daily.  Gelatine  as  a  substitute  for  albuminous  articles  of  food 
is  strongly  recommended  because  it  is  easily  digested  in  the  duodenum, 
and  does  not  induce  putrefactive  products  as  does  albumin.  Then, 
again,  by  the  substitution  of  a  larger  proportion  of  carbohydrates  we 
may  diminish  the  growth  of  putrefactive  bacteria  in  the  intestine,  and, 
by  excess  of  protein,  the  fermentative  group.  Sugar,  toast,  and  dex- 
trinized  flour  also  form  the  most  advisable  varieties  of  carbohydrates 
for  short  periods  because  so  readily  absorbed.  In  fact,  the  diet  for 
testing  intestinal  functions  (page  167),  modified  in  this  way,  forms 
the  best  basis  for  their  substitution,  with  the  exception  of  the  milk, 
which  may  at  first  be  digested  by  lactone  tablets  and  then  later  un- 
modified milk  substituted.  The  best  medicinal  means  for  the  control 
of  this  intestinal  indigestion  is  dilute  hydrochloric  acid,  in  doses  sug- 
gested under  Gastric  Diseases,  or  acidol.  Often  the  first  few  doses, 
in  conjunction  with  the  change  in  diet,  are  sufficient  to  check  the  fre- 
quent movements.  Pankreon  will  also  improve  the  digestion  and  ab- 
sorption of  the  predominant  elements  in  the  stool,  starch  and  meat 
fibers,  and  temporarily  check  the  diarrhea.  It  may  be  found  neces- 
sary to  employ  the  tannin  preparations  (tannalbin,  tannigen,  etc.)  or 
the  bismuth  preparations  (subcarbonate,  subgallate — dermatol — etc.) 
temporarily,  but  their  use  should  be  confined  to  the  smallest  doses  and 
should  cease  at  the  earliest  possible  moment,  as  by  restricting  the  peri- 
stalsis they  make  the  patient  more  comfortable,  but  aid  putrefaction 
or  fermentation.  It  has  been  our  experience  that,  by  too  energetic 
treatment,  we  may  produce  the  other  extreme — confined  bowels.  In 
this  case  laxatives  must  never  be  employed  because  they  frequently 
bring  back  the  former  condition  in  an  exaggerated  form;  it  is  much 
better  to  employ  enemata,  and  perhaps  give  a  little  petroleum  or  agar- 
agar. 

INTESTINAL  FERMENTATIVE  INDIGESTION. 

Intestinal  fermentative  indigestion  has  an  existence  as  a  disease  based 
largely  on  fecal  findings  and  the  readiness  with  which  fermentative 
changes  occur  in  the  stool,  either  standing  in  a  warm  room  or  in  a  brood 
oven.  Many  a  time  a  stool  remaining  a  few  hours  in  an  air-tight  jar  in 
our  laboratory  has  developed  by  fermentation  such  a  volume  of  gas 
that,  on  removing  the  cover,  the  greater  portion  of  the  contents  of  the 
jar  have  been  blown  out.     A  strong  acid  reaction  has  also  been  de- 


FUNCTIONAL  DISTURBANCES   OF   INTESTINALi  DIGESTION  403 

veloped.  Furthermore,  if  in  a  stool  of  this  kind,  examined  fresh,  many- 
starch  granules  are  found,  all  these  starch  fragments  will  have  vanished 
after  being  allowed  to  stand  in  an  air-tight  jar  in  a  warm  place.  From 
this  it  can  be  readily  seen  that  the  basis  of  this  disease  is  a  much 
impaired  utilization  of  starch  and  the  presence  in  the  intestine  of  many 
fermentative  organisms.  The  seat  of  this  failure  to  utilize  starch  is  in 
the  ileum,  and  the  starch  particularly  affected  is  that  inclosed  in  the 
cellulose,  which  in  the  normal  individual  is  digested  to  a  certain  extent, 
but  fails  utterly  of  digestion  in  persons  suffering  from  this  disorder. 
These  unabsorbed  portions  of  starch  and  hemicellulose  afford  an  admir- 
able culture  medium  for  fermentative  organisms,  which  they  apparently 
utilize  to  the  limit.  The  main  distinction  between  this  and  the  previous 
abnormality  is  that  here  starch  alone  fails  of  digestion,  while  there  it 
may  be  fat,  protein,  or  starch,  or  any  two ;  in  other  words,  it  is  not  spe- 
cific in  its  failure.  Patients  declare  that  they  have  suffered  from  it  for 
years  and  cannot  tell  exactly  when  it  did  begin.  Any  acute  attacks  of 
fermentative  diarrhea  are  not  of  this  variety,  but  of  the  first  described 
when  the  stomach  is  simultaneously  involved.  Occasionally  we  get  the 
history  of  recurrent  attacks  and  periods  of  well-being  between  them. 
Patients  can  even  state  what  articles  of  food  bring  on  an  attack,  which 
they  religiously  avoid,  such  as  uncooked  fruit,  Graham  bread,  and  po- 
tatoes. Again,  individuals  acquire  this  form  of  indigestion  on  an  ex- 
clusive vegetable  diet,  either  on  their  own  volition,  as  a  fad,  or  because 
it  was  recommended  by  a  physician  on  account  of  a  tendency  to  gout, 
arteriosclerosis,  or  renal  disease.  The  stools,  which  number  from  two 
to  six  during  the  day,  are  not  necessarily  liquid,  but  semisolid,  ex- 
tremely acid,  and  "burn"  the  anus,  as  patients  complain.  There  is 
extreme  flatulency,  both  at  the  time  of  stool  and  at  other  times,  and 
complaint  is  made  of  the  constant  rumbling  of  the  bowels.  Colics  are 
not  usual,  but  a  temporary  spasm  of  a  portion  of  the  intestine  may 
cause  extreme  distention  of  the  abdomen,  so  great,  in  fact,  that  women 
must  often  lay  aside  their  corsets.  Usually  no  complaint  is  made  of 
the  stomach  functions;  in  fact,  such  patients  often  boast  of  their  ex- 
cellent gastric  digestion  and  cannot  understand  why  the  lower  abdomen 
should  prove  so  troublesome.  The  general  condition  of  the  patient 
may  remain  excellent  and  the  nutrition  unimpaired,  but  fretfulness 
soon  supervenes,  sometimes  associated  with  weariness,  dizziness,  and 
occasional  headaches.  Physical  examination  shows  a  somewhat  dis- 
tended abdomen,  the  muscles  are  moderately  contracted,  there  is  con- 
siderable tympany  in  parts,  and  the  gurgling  noises  are  very  noticeable. 
Many  a  time  it  has  been  our  lot  to  examine  the  gastric  contents  in 


404  DISEASES   OF   THE   DIGESTIVE   TRACT 

these  diarrheas,  thinking  to  find  an  aehylia,  and  almost  as  often  the  re- 
sults were  perfectly  normal,  so  that  we  can  easily  differentiate  this 
variety  from  the  gastrogenous. 

The  feces  form  the  best  evidence  of  the  presence  of  this  variety  of  in- 
testinal indigestion.  They  are  very  light-colored,  of  acid  reaction,  due 
to  acetic  and  butyric  acids,  and,  when  a  small  portion  is  rubbed  on  a 
slide,  gas  bubbles  can  be  seen  to  escape,  and,  as  a  whole,  the  stool  has 
a  frothy  appearance.  No  mucus  is  found  in  uncomplicated  cases,  but, 
when  to  a  fragment  of  the  stool  iodine  is  added  and  it  is  examined 
under  the  microscope,  an  abundance  of  starch  granules  can,  be  seen, 
and,  if  the  patient  is  on  the  test  diet,  these  are  found  largely  within  the 
potato  cells,  though  they  may  be  isolated,  and  some  cells  may  be  dis- 
tinctly seen  with  their  outline  stained  yellow,  but  empty.  (See  Fig. 
37.) 

Another  noticeable  feature  is  the  great  number  of  oval  microbes,  con- 
taining granulose,  which  stain  equally  blue,  and  are  arranged  in  chains 
or  groups.  In  addition,  many  yellow-stained  yeast  spores  are  found 
and  a  few  long  unstained  bacilli  (lactic  acid).  The  fermentation  test 
shows  the  excessive  evolution  of  gas,  a  markedly  increased  acid  reaction 
of  the  fluid,  and  the  disappearance  of  a  large  part  of  the  starch 
granules  when  examined  under  a  microscope.  The  search  with  the 
naked  eye  for  starch  fragments  may  be  worth  while,  but  our  experience 
is  that  it  is  largely  futile,  and  one  smear  under  the  microscope  will 
give  more  information  than  an  hour's  observation  with  the  unaided 
eye.  Hydrobilirubin  is  present  in  the  feces  in  normal  quantities  and 
never  bilirubin,  unless  the  constant  irritation  of  these  fermentative 
acids  has  produced  a  catarrh,  when  bilirubin  and  mucus  may  be  present. 
These  attacks  of  catarrh  are  common,  and  during  them  it  is  diffi- 
cult to  trace  the  condition  to  a  fermentative  indigestion,  since  the 
mucus,  meat,  and  fatty  acids  form  a  feature  of  the  slide,  but  the  in- 
flammatory state  may  be  overcome  when  the  patient  returns,  not  to 
health,  but  to  the  former  fermentative  diarrhea  on  the  least  provoca- 
tion. 

The  chief  points  in  diagnosis  are  the  character  of  the  stool — not  par- 
ticularly the  absence  of  mucus,  meat  fibers,  connective  tissue,  and  fat, 
but  the  predominance  of  starch  and  the  lack  of  participation  on  the 
part  of  the  stomach. 

The  prognosis  is  unfavorable  in  that  one  cannot  be  restored  to  such 
a  state  that  all  vegetables  can  be  freely  indulged  in.  Much  like  dia- 
betes, there  is  a  cellulose  limit  established  in  such  individuals  beyond 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL   DIGESTION  405 

which  they  dare  not  go.  Long  moderate  restriction,  however,  increases 
this  tolerance  to  such  an  extent  that  a  marked  increase  may  be  indulged 
in  without  harm,  but  probably  the  period  never  returns  when  restric- 
tions are  not  necessary. 

Treatment. — The  treatment  of  this  form  of  intestinal  indigestion 
often  demands  only  a  regulation  of  the  diet  for  complete  restoration  to 
temporary  normal  conditions.  As  the  starch  is  the  source  of  the  dis- 
order, it  is  possible  to  exclude  this  almost  wholly  from  the  diet  for  a 
few  days,  and  the  employment  of  a  strict  fat-protein  regimen  may  be 
instituted,  which  is  not  so  easily  carried  out  as  in  diabetes,  for  we 
must  also  exclude  salads  and  green  vegetables.  We  may,  however, 
allow  a  small  quantity  of  sugar,  either  cane  or  milk,  to  replace  the  loss 
of  other  food,  since  these  sugars,  on  account  of  their  rapid  absorption, 
leave  no  residue  for  the  culture  of  the  fermentative  organisms.  The 
diet  list,  adapted  from  A.  Schmidt,  is  as  follows : 

DIET   LIST   IN   FERMENTATIVE   INTESTINAL  INDIGESTION. 

Breakfast. — Tea  or  coffee  free  from  caffeine  (Cafe  des  Invalides), 
with  milk  or  cream,  two  soft  boiled  eggs,  two  lumps  of  sugar  or  a  des- 
sertspoonful of  fruit  jelly. 

11  a.  m. — Bouillon,  with  a  beaten  egg  cooked  in  it,  and  some  minced 
ham. 

Dinner. — Bouillon,  fish  cooked  with  butter  or  tenderloin  steak ;  gela- 
tine, with  a  little  sugar  and  cream. 

4  p.  m. — Bouillon  and  chopped  ham. 

Supper. — Cold  chicken  or  turkey,  omelet,  and  tea. 

According  to  our  experience,  after  two  days  of  this  diet  the  stool 
changes  its  complexion  completely;  it  is  found  darker,  alkaline  in  re- 
action, and  no  longer  can  one  find  fermentative  organisms  in  it.  If 
the  change  does  not  take  place  promptly,  it  is  well  to  continue  the 
diet  for  two  days  longer ;  then  the  change  to  the  ordinary  diet  should 
not  take  place  at  once,  but  more  sugar  should  be  added,  and  honey 
may  be  employed,  while  later  the  patient  may  have  toast  or  zwieback. 
Here,  too,  finely  ground,  toasted  bread,  or  croutons,  makes  an  excellent 
addition,  without  the  danger  of  recurring  diarrhea.  The  thick  soups 
made  with  oatmeal  or  flour  may  be  next  added  and  also  well-cooked  rice. 
Potatoes  should  be  the  last  thing  given,  and  then  only  as  puree ;  they 
are  particularly  liable  to  cause  a  return  of  the  indigestion,  and,  if  pos- 
sible, patients  should  be  induced  to  go  without  them.  Pankreon  and 
bismuth  subsalicylate  may  be  employed  if  the  diet  does  not  check  the 


406  DISEASES   OF   THE   DIGESTIVE   TRACT 

discharges,  for  fermentative  growths  can  be  controlled  much  more 
readily  than  putrefactive.  A  favorite  prescription  of  ours  for  this  con- 
dition is  as  follows : 

IJ     Mentholis, 

Resorcinolis,  aa  2.0  or  Ya  dram 

Bismuthi  subsalicylatis .6.0  or  1^^  drams 

M.     Fac  in  capsulas  XX. 

Sig. :     One  every  four  hours. 

After  the  attack  is  over,  the  quantity  of  vegetables  must  be  re- 
stricted to  only  one  vegetable  at  a  meal,  excluding  by  preference  po- 
tatoes, beets,  radishes,  and  turnips. 

HABITUAL  FUNCTIONAL  CONSTIPATION. 

Habitual  functional  constipation  is  perhaps  quite  the  most  common 
complaint  to  which  we  have  to  listen,  either  in  a  clinic,  frequented  by 
the  poor,  or  among  our  well-to-do  patients.  It  is  sometimes  looked  on 
as  increasing  in  frequency,  but,  when  we  consider  the  "Lady  Webster" 
and  other  famous  catliartic  pills,  dating  from  the  seventeenth  century, 
we  will  realize  that  this  condition  is  not  an  innovation.  We  must 
clearly  understand  what  the  patient  means  when  he  says  he  is  consti- 
pated. He  may  imply  infrequent  movements — that  is,  one  in  two  or 
three  days;  that  a  daily  movement  is  usually  hard — "hard  as  stone" 
say  the  poorer  patients;  or  he  may  mean  a  scanty  movement,  with  a 
sense  of  insufficient  defecation.  Prolapsed  or  an  unusually  long  colon 
was  long  thought  to  be  a  cause  of  infrequent  movements,  but  the  x-ray 
has  taught  us  that  this  does  not  always  follow,  nor  are  there  lacking 
those  whose  investigations  seem  to  prove  that  sometimes  the  displace- 
ments of  the  colon  are  due  to  its  primary  overloading  with  fecal  mat- 
ter ;  this  is  particularly  true,  according  to  some,  of  the  cecum  mobile  and 
dilated  sigmoid  flexure.  Weakness  of  the  adjuvant  defecating  muscles, 
especially  in  women  who  have  borne  children,  such  as  diastasis  of  the 
recti  or  paresis  of  the  abdominal  muscles  as  a  whole,  as  well  as  a  spasm 
of  the  sphincter,  are  accused,  but  the  instances  are  legion  where  no  such 
cause  is  found,  nor  can  any  obstruction  whatever  be  detected  which 
will  account  for  this  faulty  defecation.  Fleiner  thought  he  had  added 
to  our  knowledge  some  new  light  when  he  divided  constipation  into  two 
classes — an  atonic,  dependent  on  lack  of  muscular  tone  of  the  colon; 
the  other  spasmodic,  due  to  contractions  of  the  ring  muscles  at  different 
points,  but  not  always  at  the  same  point  at  all  times  in  the  same  indi- 
vidual, which  produces  as  well  colicky  pains,  rumbling  noises,  dis- 


FUNCTIONAL  DISTURBANCES   OF   INTESTINAL  DIGESTION  407 

tention  of  those  portions  of  the  tract  above  the  contraction,  and  physi- 
cally a  well-defined  cord  representing  the  contracted  portion  of  the 
canal.  Boas,  however,  basing  his  opinion  on  the  newer  palpation 
technic,  rectoscopy,  and  examination  of  the  stool,  has  declared  that  no 
evidences  of  this  condition  (spasmodic  contraction)  are  clearly  enough 
defined  to  enable  it  to  be  characterized  as  a  disease,  and,  furthermore, 
that  these  same  observations  can  be  made  at  times  in  those  suffering 
from  an  atonic  colon — indeed,  in  those  whose  defecation  is  normal. 
There  is  no  doubt  that  spasmodic  contractions  do  occur  in  the  colon, 
which  delay  the  passage  of  feces  and  rarely  cause  symptoms  of  ileus, 
but  these  are  brought  about  by  locally  diseased  portions,  and  are  to  be 
compared  to  the  cramps  of  the  sphincter  from  anal  fissure  and  dysen- 
teric patches  in  the  rectum.  These  states,  however,  have  nothing  to  do 
with  habitual  constipation,  a  condition  not  accompanied  usually  by  any 
pain,  spasm,  or  other  local  discomfort.  In  the  stomach  and  esophagus 
we  speak  of  weakened  musculature,  but  in  the  colon,  with  its  powerful 
muscles,  we  must  look  for  some  other  cause,  and  that  is  faulty  nerve 
innervation  or  overstimulation  of  the  prohibitory  nerves.  Many  ex- 
amples of  this  we 'see  in  true  spasm,  due  to  local  disease,  in  lead  poison- 
ing, in  tabes  and  myelitis,  in  carbon  dioxide  poison  from  hepatic  or 
cardiac  stasis,  and  in  neurasthenia,  but  outside  of  the  last,  which  may 
equally  as  well  be  the  result  of  constipation  as  a  cause,  the  others  are 
so  rare,  compared  with  the  enormous  distribution  of  the  disorder,  that, 
while  we  look  for  them,  we  rarely  find  them.  Atrophy  of  the  colon 
musculature  has  been  offered  as  a  cause,  but,  since  experimentally  the 
colon  has  been  freed  from  its  muscles  in  animals  and  the  feces  were  not 
at  all  delayed  in  their  course,  this  has  become  untenable,  a  conclusion 
which  is  still  further  substantiated  by  the  fact  that,  no  matter  how  ob- 
stinate or  long  continued  the  constipation  is,  stools  can  usually  be  pro- 
duced by  laxatives,  which  would  establish  the  fact  that  the  muscles  are 
unimpaired  and  will  respond  to  an  exaggerated  stimulus.  Thus  we  are 
driven  to  the  old  statement  of  Nothnagel,  ''that  the  nervous  innerva- 
tion of  the  colon  and  rectum  is  abnormal,"  and,  as  the  coroner's  jury 
used  to  render  the  verdict  in  regard  to  an  undiscovered  murderer,  ' '  per- 
petrator unknown,"  we  may  also  say,  "cause  of  faulty  innervation  un- 
known." Physiologically,  the  gases  and  volatile  acids,  formed  from 
cellulose  by  bacteria  and  other  unabsorbable  residue  of  the  food,  act  as 
inciters  of  peristalsis,  so  that  A.  Schmidt  asks  why  may  not  the  loss 
of  these  factors  account  for  the  lacking  peristalsis,  and  he  proceeds  to 
answer  this  question  by  demonstrating  that  the  constipated  possess  an 
abnormal  digestive  and  absorptive  power,  particularly  for  cellulose. 


408  DISEASES   OP   THE   DIGESTIVE   TRACT 

There  seems  to  be  much  in  this  contention.  The  bacteria  are  much  less 
in  number  in  the  feces,  there  is  an  alkaline  reaction,  indol  and  skatol  are 
not  increased  either  in  the  stool  or  urine,  and  no  fermentative  or  putre- 
factive products  are  found  after  the  brood  oven  test.  On  account  of 
this,  vastly  less  residue  is  contained  in  the  feces  of  the  constipated,  not 
only  of  nitrogenous  matter,  but  also  of  cellulose.  Curiously  enough, 
when  the  constipated  are  given  food  containing  cellulose — like  coarse 
bread,  radishes,  asparagus,  etc. — there  is  not  a  corresponding  increase 
in  the  fecal  residue  as  in  the  normal  individual,  nor  is  the  peristalsis 
approximately  increased.  This  is  not  only  a  laboratory  experience 
(Lohrisch) ,  but  also  a  clinical  observation.  For  instance,  the  first  meal 
in  a  vegetarian  restaurant  will  often  cause  two  or  three  movements  in 
those  with  normal  colon  innervation,  but  will  produce  no  eifect  on  the 
constipated. 

Symptoms. — The  symptoms  of  functional  constipation  are  varied,  or 
may  be  entirely  absent.  It  is  a  generally  accepted  notion  among  the 
laity  that  a  stool  should  occur  daily,  and,  when  this  fails,  individuals, 
though  possessed  of  good  digestion  and  appetite,  become  restless  and 
are  much  disturbed  mentally  over  this  impaired  function.  Then, 
again,  the  fear,  ungrounded  though  it  may  be,  of  acute  obstruction,  is 
ever  present  with  the  patient  and  recourse  is  had  to  laxatives,  which, 
as  all  know,  increase  the  difficulty  until  the  greater  effort  necessary 
to  secure  a  daily  movement  brings  him  to  the  physician.  Then,  an- 
other group  does  have  actual  discomfort  in  this  condition;  there  is  a 
dull  sensation  in  the  head,  increasing  at  times  to  an  ache,  and  dizziness 
often  follows;  rush  of  blood  to  the  head,  inability  to  concentrate  one's 
mind  on  mental  work,  and  a  feeling  of  distention  in  the  lower  abdomen 
are  complained  of.  These  are  the  symptoms  which  are  so  often  as- 
cribed to  autointoxication,  with  which  they  probably  have  nothing  to 
do.  Others  complain  of  purely  local  difficulty — a  moderate  tenesmus^ 
unrelieved  by  the  scanty  stool  which  often  follows;  vague  painful 
sensations,  particularly  over  the  cecum,  often  interpreted  by  the  pa- 
tient as  appendicitis,  and  sometimes  at  the  flexures  of  the  colon,  ex- 
aggerated by  deep  inspiration,  and  always  demanding  an  examination 
of  the  lower  pleura,  though  no  ^  increased  respiration  is  present ; 
gurgling  is  heard  in  the  abdomen,  and  true  colic  may  sometimes  occur 
("spastic  form").  Then,  too,  hemorrhoids  often  accompany  consti- 
pation, which  may  be  of  the  bleeding  variet.y,  or  are  occasionally  in- 
flamed. The  patient's  description  of  the  difficulty  of  defecation  is 
as  varied  as  his  other  symptoms.  Some  declare  that  the  feces  are 
packed  above  the  anus,  but  cannot  be  forced  out.     Others  complain 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL   DIGESTION  409 

that,  in  spite  of  daily  stools,  they  know  that  a  large  part  of  the  fecal 
matter  is  retained  and  that  the  abdomen  is  gradually  filling  up.  Still 
others  claim  that  they  go  to  stool  many  times  daily,  but  only  a  few 
fragments  are  discharged,  without  any  relief  of  their  desire;  then 
occasionally,  without  laxatives,  there  comes  an  enormous  stool,  made 
up  of  feces,  blood  stained  or  with  mucus  adherent,  accompanied  by 
some  pain,  a  form  of  the  atonic  constipation.  At  other  times,  associ- 
ated with  sphincter  cramp,  there  is  a  stool  of  lead  pencil  or  ribbon 
shape  form,  or  it  may  be  made  up  of  small  round  fragments  like 
marbles.  Such  persons,  after  the  constant  use  of  laxatives,  have  semi- 
solid or  even  fluid  stools,  showing  that  there  is  no  organic  obstruction, 
or  the  form  would  be  maintained  even  after  cathartics.  Often,  on 
close  examination,  these  bizarre  forms  of  stool  are  found  not  to  be  un- 
usually dry  or  hard,  but  assume  this  appearance  from  spasm  of  the 
lowest  portion  of  the  tract. 

Physical  examination  throws  but  little  light  on  the  condition.  The 
individual  may  be  thin  or  obese ;  the  abdomen  may  be  soft  and  flat  or 
moderately  distended;  there  may  be  areas  of  tympany,  particularly 
over  the  cecum  and  ascending  colon,  while  these  parts  may  be  slightly 
tender  to  pressure  or  entirely  without  sensitiveness;  often  the  con- 
tracted portion  of  the  colon  can  be  rolled  under  the  finger,  and,  when 
relaxed,  the  gush  of  contents  can  he  felt  to  pass  through  it.  Rarely 
can  fecal  masses  be  felt  in  the  descending  colon  and  sigmoid,  and 
those,  according  to  our  observation,  only  in  enteroptotic  women  with 
thin  abdominal  walls. 

To  diet  has  been  ascribed  much  of  the  constipation  of  today,  and, 
"while  it  is  less  common  on  a  mixed,  well-proportioned  ration,  still  the 
sailors,  whose  deprivation  of  vegetables  and  fruit  has,  at  least  in  past 
days,  been  a  subject  of  remark,  have  never  been  particularly  subject 
to  it.  i\Iany  incidental  causes  of  this  disturbed  nerve  innervation  of 
the  colon  can  be  removed,  such  as  the  neglect  of  the  desire  for  defeca- 
tion, so  common  from  motives  of  inconvenience  or  lack  of  time,  the 
abuse  of  laxatives,  which  appear  to  many  as  the  ' '  easiest  way ' '  rather 
than  a  recourse  to  change  of  diet;  further,  the  indifference  of  both 
patient  and,  sad  to  relate,  often  of  the  physician  to  relaxed  abdominal 
walls  after  confinement.  There  are  also  many  minor  moments  which 
often  start  the  train  of  symptoms — an  ocean  voyage,  with  its  ex- 
cessive eating  and  little  exercise,  an  early  train  which  one  must  catch 
immediately  after  breakfast,  the  usual  time  among  many  for  the  stool, 
etc.  The  commonest  cause  of  the  so-called  spastic  form  is  an  acute 
catarrh  of  the  colon,  accompanied  by  diarrhea,  which  is  followed  by  a 


410  DISEASES   OP   THE   DIGESTIVE   TRACT 

compensatory  cessation  from  stool,  and  from  this  a  chronic  condition 
arises.  Then,  often  it  is  the  result  of  a  pure  reflex  from  an  adhesion 
after  an  appendectomy  or  an  operation  on  the  genital  organs,  or 
the  irritation  may  be  more  local — hemorrhoids  and  fissure;  in  many 
instances  an  atonic  condition  of  the  colon  was  followed  by  the  spastic. 
It  has  often  occurred  to  those  that  make  numerous  examinations  of 
gastric  contents  that  the  stomach  is  not  always  above  reproach  for  this 
disorder,  either  producing  an  excess  of  gastric  juice  or  holding  back 
the  fluid  on  account  of  a  narrowed  pylorus  or  impaired  muscular 
tone.  Which  is  primary,  the  constipation  or  the  hypergecretioQ, 
authorities  cannot  decide.  A.  Schmidt's  view  is  that,  in  pursuance 
of  his  theory  of  overactive  digestion  of  cellulose,  the  superefficient 
gastric  juice  dissolves  the  inclosing  pectin  substances,  and  hence  en- 
courages greater  absorption,  less  residue,  and  constipation.  When 
patients  complain  about  the  lower  abdomen  in  constipation,  their 
plaints  are  usually  much  the  same — fullness  and  pressure — though 
every  objective  sign  is  wanting;  there  is  no  meteorism,  no  excessive 
discharge  of  flatus  or  objective  tenderness  to  pressure ;  in  other  words, 
the  symptoms  are  largely  those  of  neurasthenia.  In  fact,  a  strong 
diagnostic  point  in  favor  of  the  functional  character  of  the  disease 
is  this  great  disparity  between  the  voluble  complaints  of  the  patient 
and  this  absence  of  objective  signs.  True  meteorism  really  begins 
only  when  from  stenosis  or  peritonitis  there  is  an  obstruction  in  the  cir- 
culation in  the  vessels  of  the  abdominal  organs,  and  this  is  never  found 
in  functional  constipation.  It  happens  rarely  in  very  thin-walled 
women  that  one  can  see  a  portion  of  the  intestine  become  rigid  (spastic 
form),  but  even  then,  with  a  rumbling  sound,  it  soon  disappears,  only 
to  appear  at  another  point.  This,  as  can  be  seen,  differs  very  de- 
cidedly from  the  true  stenosis,  which  is  fixed.  With  these  borborygmi 
come  all  gradations  of  abdominal  discomfort,  from  a  slight  ache  to 
actual  colicky  pains,  and  the  favorite  sites  for  these  are  at  the  hepatic 
and  splenic  flexures,  where  spasm  of  the  colon  seems  most  common ;  in 
fact,  one  can  often  follow  up  a  distended  tympanitic  colon  from  the 
cecum  to  the  right  costal  border,  only  to  lose  it  under  the  liver,  and  at 
the  next  visit  of  the  patient  to  the^clinic  it  has  vanished.  When  it  is 
thought  that  one  feels  scybala  in  the  sigmoid,  the  patient  should  be 
sent  home  for  a  good  dose  of  castor  oil  and  told  to  return  in  a  couple 
of  days,  when  it  often  turns  out  that  only  the  contracted  portion  of 
that  part  of  the  colon  was  felt. 

The  x-ray  examination  of  the  constipated  shows  no  delay  until  the 
bismuth  residue  enters  the  cecum,  so  that  after  twenty-four  hours 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL   DIGESTION 


411 


none  or  very  little  has  reached  the  transverse  colon.  From  these  pic- 
tures it  would  seem  as  if  the  process  of  thickening,  undergone  by  the 
feces  at  the  middle  of  the  transverse  portion  in  normal  individuals,  be- 
gan here  in  the  constipated. 


Fig.  79. — Radiogram  of  marked  looping  of  colon,  accompanied  by  constipation.      (Collection 

of  Dr.  Arial  W.  George.) 

The  second  form  is  found  in  cases  of  marked  looping  of  the  colon, 
and  here  the  delay  is  not  so  much  in  the  cecum  as  distributed  equally 
throughout  the  whole  colon.     Here  it  is  distinctly  seen  that  the  colon 


412 


DISEASES   OF   THE   DIGESTIVE   TRACT 


gives  an  equally  intense  shadow  throughout  its  course ;  in  other  words, 
the  stasis  is  not  confined  to  the  ascending  colon. 

One  should  never  neglect  the  introduction  of  the  well-guarded  finger 
into  the  rectum  of  every  patient  complaining  of  constipation,  for  often 


Fig.  80. — Radiogram  of  rectum  packed  witli  fi 


(Collection  of  Dr.  Arial  W.  George.) 


a  spasm  of  the  sphincter  will  be  found,  dependent  on  hemorrhoids  and 
fissure,  and  the  rectum  packed  with  feces.  This  is  not  constipation, 
but  local  obstruction,  and  can  be  treated  only  by  removal  of  the  cause ; 
on  the  contrary,  when  true  functional  constipation  exists,  the  rectum 
is  usually  found  empty. 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL   DIGESTION  413 

The  stools  of  those  constipated,  when  examined,  show  a  vast  variety 
of  gross  forms.  First,  we  have  the  double  conical  type  of  diminished 
length,  which  may  not  be  unnaturally  hard,  but  is  often  smeared  with 
blood;  this  is  undoubtedly  found  with  spasmodic  contraction  of  the 
anal  sphincter.  Then  there  is  the  only  partially  formed  stool,  whose 
cylindrical  shape  is  lost  by  the  separation  of  its  individual  parts  when 
passed,  small  scybala,  which  are  not  especially  hard,  but  very  tena- 
cious, and  disintegrate  with  difficulty;  these  are  said  to  be  associated 
with  the  spastic  period.  Then,  last,  we  have  the  hard  form,  dry  balls, 
which  are  often  faceted  like  gallstones  and  are  discharged  singly; 
these,  according  to  A.  Schmidt,  accompany  the  atonic  state  of  the 
colon.  These  balls  of  feces  are,  as  a  rule,  covered  with  shreds  of 
mucus  and  often  blood  stained ;  this  mucus  is  clearly  the  effect  of  the 
irritation  of  the  fecal  masses  and  not  primary.  When,  on  the  con- 
trary, small  shreds  of  mucus  are  discharged  unmixed  with  fecal  mat- 
ter, the  constipation  is  secondary,  and  there  is  a  so-called  mucous 
colitis. 

As  far  as  the  nervous  symptoms  associated  with  constipation  are 
concerned,  to  w^hich  attention  has  already  been  called,  it  is  very  doubt- 
ful if  the  abnormal  defecation  has  anything  to  do  with  them,  but 
forms  only  a  coordinated  symptom  of  the  general  neurasthenic  condi- 
tion. As  a  proof  of  this  conclusion,  we  may  call  attention  to  the  fact 
that,  if  the  movements  be  regulated  by  diet  and  laxatives,  some  of  the 
manifestations,  like  fullness  in  the  head  or  dizziness,  will  be  avoided, 
but  fugitive  pains  and  insomnia  take  their  place  in  the  complaints  of 
the  patient. 

As  some  of  the  results  of  continued  constipation,  we  may  mention 
hemorrhoids,  which  undoubtedly  may  be  caused  by  the  long  stay  of 
these  hardened  masses  in  the  lower  rectum  and  the  overfilling  of  the 
veins  during  the  straining  at  stool.  True  enteroliths,  large  masses 
which  increase  gradually  from  a  small  scybalum  by  successive  layers  of 
fecal  matter,  much  like  a  school  boy's  snow  ball  which  is  rolled  over 
the  soft  snow,  are  occasionally  found  as  a  result  of  constipation,  but, 
according  to  our  observation,  only  in  elderly  people,  where  they  often 
arouse  a  suspicion  of  a  malignant  growth.  They  frequently  lose  the 
quality  of  plasticity  by  which  they  recede  before  the  examining  finger, 
the  best  means  we  have  for  their  detection,  and,  by  producing  second- 
ary inflammatory  disturbances  in  the  mucous  membrane  or  even 
ulcer,  and,  as  Virchow  found,  localized  peritoneal  invasion  and  adhe- 
sions, thus  become  painful  on  pressure.  They  are  usually  situated  in 
the  rectum  or  sigmoid,  and  in  a  case  under  our  observation  one  was 


414  DISEASES   OF   THE   DIGESTIVE   TRACT 

found  in  the  transverse  colon.  They  are  dangerous,  largely  because 
they  sometimes  acquire  the  size  of  a  child's  head,  and  may  cause  total 
obstruction  or  perforation  of  the  intestinal  wall  and  general  peri- 
tonitis. 

Extensive  colon  catarrh  very  rarely  arises  from  chronic  constipa- 
tion, though,  when  a  spastic  condition  of  the  intestine  intervenes, 
mucus  may  be  more  abundant  and  the  condition  differentiated  from 
a  mucous  colitis  with  great  difficulty.  All  of  us  have  seen  instances  of 
painful  inflammatory  disturbances  in  the  cecal  region,  often  ac- 
companied by  rise  in  temperature,  and  relieved  in  a  day  or  two  by  a 
mild  laxative.  This  condition,  formerly  known  as  typhlitis  stercoralis, 
was  supposed  to  be  due  to  the  fecal  accumulation  in  this  portion  of 
the  colon,  but,  as  the  contents  here  must,  with  a  very  few  exceptions, 
be  liquid,  it  can  hardly  be  possible  that  any  irritation  may  arise,  such 
as  is  found  in  the  sigmoid  with  the  enteroliths.  It  would  seem  much 
more  probable  that  undue  fermentation  or  putrefaction  must  be  the 
exciting  cause.  At  least  the  contention  of  some  surgeons  that  the  ap- 
pendix is  always  involved  is  untenable,  for  spasm  of  the  rectus  has 
never  been  seen  by  us,  and  the  appearance  and  general  condition  of 
the  patient  are  always  indicative  of  a  much  less  violent  disturbance 
than  an  inflamed  appendix.  Colic  and  fever  are  two  conditions 
which  arise  from  these  hardened  masses  of  feces  in  the  intestine.  The 
former  may  cause  the  most  excruciating  pain,  accompanied  by  col- 
lapse and  meteorism,  demanding  one  or  two  injections  of  morphine, 
and  ceasing  only  after  two  or  three  free  movements  of  the  bowels. 
The  latter  is  less  strongly  substantiated  and  may  be  coincident,  yet 
rises  of  temperature  occur,  with  no  other  condition  than  that  of  con- 
stipation, and  disappear  on  free  catharsis. 

Accumulations  of  fecal  matter,  too,  may  cause  the  presence  of 
nucleoalbumin  and  mucous  casts  (cylindroids)  in  the  urine,  and,  while 
no  one  attempts  to  associate  nephritis  with  constipation  in  a  causal  re- 
lation, still  a  pyelitis  may  be  aroused  by  the  colon  bacillus,  whose 
growth  and  migration  through  the  lymph  vessels  to  the  urinary  tract 
are  encouraged  by  stagnation  of  intestinal  contents. 

The  heart  symptoms  associated  with  constipation  are  mild  pre- 
cordial distress  (much  commoner  after  mealtime  than  after  exercise), 
palpitation,  and  intermission.  It  is  very  improbable  that  coprostasia 
is  an  instrumental  agent  in  producing  these  symptoms,  but  both  are 
the  outcome  of  the  patient's  neurasthenic  condition,  or  the  cardiac 
irregularities  (providing  the  heart  is  muscularly  insufficient)  may  be 
due  to  accumulations  of  gas  in  the  splenic  flexure.     Similar  conditions 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL  DIGESTION  415 

pertain  in  bronchial  asthma  and  epilepsy,  while  there  is  no  substantia- 
tion for  the  belief  that  chlorosis  springs  from  constipation.  The  diag- 
nosis comprises  three  points : 

1.  To  determine  whether  the  patient  actually  is  constipated,  for 
many  declare  themselves  constipated  when  they  consider  the  stool 
insufficient  and  themselves  unrelieved  by  defecation,  while  an  inspec- 
tion of  the  stool  shows  its  adequacy. 

2.  "We  must  learn  by  digital  examination  whether  there  is  actual 
constipation  or  whether  the  rectum  remains  filled  with  fecal  matter 
from  sphincter  cramp  arising  from  fissure  or  hemorrhoids,  or  the  much 
rarer  rectal  cancer. 

3.  Whether  we  are  dealing  with  a  functional  disorder  or  there  is 
an  actual  organic  obstruction  at  some  point  in  the  tract,  brought  about 
by  bands,  kinks,  twists,  adhesions,  or  the  graver  evil — a  malignant 
growth. 

This  differentiation  will,  in  the  early  stages  of  true  obstruction,  try 
all  our  means  of  examination  to  the  breaking  point,  not  excluding 
rontgenology,  and  then  often  leave  us  somewhat  undecided. 

Treatment. — The  treatment  often  requires  the  utmost  ingenuity  of 
the  physician.  First,  to  break  up  the  habit  of  the  free  use  of  laxa- 
tives, whose  use  always  appeals  to  the  laity  because  the  temporary 
results  are  certain,  and  it  is  much  less  burdensome  to  swallow  your 
pill  at  bedtime  than  to  observe  rules  of  diet,  cold  baths,  etc.;  hence 
many  physicians,  when  the  constipated  apply,  simply  change  the  laxa- 
tive. But  after  the  underlying  conditions  of  the  constipated  have 
been  studied,  gastric  hypersecretion  or  stasis,  neurasthenia,  and  the 
special  state  of  the  colon  noted  (spasm  or  atony),  and  the  anal 
sphincter  investigated  (spasm  with  full  rectum),  then  vigorous  meas- 
ures must  be  adopted  to  remedy  the  special  form  found,  consisting  of 
dietary,  physical,  and  medicinal  measures,  the  use  of  enemata,  and 
possibly  an  operation. 

Diet. — The  diet,  based  on  physiologic  standpoints,  must  consist  of 
coarse  foods  containing  much  cellulose  (like  Graham,  bro"v^Ti,  and  rye 
bread),  all  the  breakfast  foods  (particularly  oatmeal),  green  vege- 
tables (like  lettuce,  green  pease,  cucumbers,  pickles,  and  cabbage),  and 
all  fruits  and  berries.  These  substances  all  act  by  producing  a 
voluminous  stool,  but  we  have  others  which  have  a  stimulating  effect 
on  peristalsis,  such  as  milk  sugar,  buttermilk,  cider,  and  honey,  while 
salted  articles  (like  salt  codfish,  mackerel,  and  finnanhaddie)  have  the 
same  effect.  On  the  other  hand,  certain  articles  of  food,  like  cocoa, 
rice,  macaroni,  and  cheese,  have  the  opposite  effect  of  retarding  per- 


416  DISEASES   OF    THE   DIGESTIVE   TRACT 

istalsis,  and  should  be  avoided.  When  there  is  a  spastic  condition  of 
the  colon,  with  painful  sensations,  colicky  attacks,  and  much  flatulency, 
some  authorities  would  eliminate  the  coarser  articles,  like  cabbage, 
radishes,  beet  greens,  and  celery,  while  others  would  persist  in  a  con- 
sistent anticonstipation  diet  containing  these  foods,  even  if  mucous 
colitis  were  present.  These  varieties  of  food,  arranged  in  a  diet  list, 
would  read  as  follows : 

DIET   LIST   IN    CONSTIPATION. 

On  rising. — A  glass  of  cold  water,  with  a  tablespoonful  of  milk 
sugar  or  a  pinch  of  salt. 

Breakfast. — Fruit  (grapefruit,  cantaloupe,  oranges,  or  apples),  cov- 
ered with  cream  and  sugar,  Graham  or  rye  bread  (toasted  if  de- 
sired), with  one  or  two  pats  of  butter. 

11  a.  m. — A  glass  of  buttermilk,  with  a  tablespoonful  of  milk  sugar, 
or  some  fruit. 

Dinner. — Clear  soup;  meat  or  fish,  with  gravy;  spinach,  cauliflower, 
Brussels  sprouts,  beet  greens,  or  celery;  a  salad;  cooked  or  canned 
fruit,  with  cream ;  a  glass  of  Rhine  wine  or  cider. 

4  p.  m. — A  rye  bread-and-butter  sandwdch,  thickly  spread  with  jelly 
or  honey. 

Supper. — Salt  herring  or  codfish  and  cream  or  anchovy  salad,  cold 
cornbeef  or  hash  of  the  same;  Graham  bread  or  toast,  with  butter; 
olives,  a  salad,  coffee  or  a  glass  of  malt. 

Bedtime. — A  glass  of  water,  with  a  tablespoonful  of  milk  sugar. 

It  sometimes  happens  that  with  this  large  volume  of  food,  contain- 
ing so  much  cellulose,  the  patient  at  first  complains  of  colicky  pains, 
and  then  careful  examination  will  show  a  spastic  condition  of  the 
colon.  Under  such  circumstances  a  preliminary  diet  containing  the 
same  articles  of  food,  wdth  the  exclusion  of  the  coarse  bread  and 
salads,  may  be  necessary,  when  a  gradual  return  to  the  full  diet  may 
be  made  without  discomfort.  Then,  again,  even  in  those  in  whom  the 
atonic  state  of  the  colon  is  present,  this  coarse  diet  may  fail  to  produce 
any  effect  on  the  frequency  or  consistence  of  the  stools,  either  because, 
having  already  been  tried  by  the  patient,  the  fermentative  acids  and 
gases  have  no  effect  on  the  jaded  intestine,  or  on  account  of  the  per- 
sistent use  of  laxatives,  but  perhaps  more  commonly  because  these 
people,  as  A.  Schmidt  maintains,  can  digest  cellulose  so  well  that  little 
residue  remains.  Under  such  circumstances,  articles  must  be  added 
to  the  food  which  are  known  to  be  indigestible  and  which  leave  the 
intestine  as  they  enter  the  mouth.     One  of  such  articles  is  agar-agar. 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL   DIGESTION  417 

which  can  be  procured  at  any  drug  store,  cooked  in  vegetables  or 
fruit,  and  eaten  without  any  distaste.  The  quantity  is  dependent  on 
the  results;  with  some  a  few  strands  suffice,  others  must  use  a  great 
deal  to  produce  any  result.  The  regulin,  which  A.  Schmidt  has 
fathered,  is  expensive,  and  has  no  value  beyond  crude  agar-agar,  apart 
from  the  cascara  sagrada  which  has  been  added,  and  which  patients 
can  take  during  the  early  part  of  the  treatment  in  the  form  of  the 
extract  at  bedtime,  in  steadily  decreasing  doses,  while  the  agar-agar 
is  being  pushed.  Purified  petroleum  is  another  substance  which  es- 
capes digestion  and  absorption,  and  can  be  used  in  tablespoonful  doses 
in  almost  unlimited  quantities  until  a  laxative  effect  is  produced. 
Copious  water  drinking  is  also  desirable,  particularly  where  excess  of 
perspiration  or  urine  (diabetes)  is  a  contributing  factor,  though, 
physiologically,  excess  of  water  has  not  been  found  to  change  the  con- 
sistency of  the  stools,  yet  in  diarrheas  ice  water  will  very  often  cause 
a  movement  immediately  after  being  taken,  long  before  it  could  be 
absorbed.  The  attempts  to  change  the  bacterial  growth  in  the  in- 
testine by  the  use  of  cultures  of  lactic  acid  bacilli  have  not  been  very 
successful ;  still,  the  persistent  drinking  of  buttermilk  or  yoghurt,  not 
fermented  more  than  one  day,  may  cause  the  desired  transformation. 
We  hear  at  times  of  certain  individuals  who  have  accomplished  a  cure 
by  the  ingestion  of  sea  sand,  but  this  has  never  secured  the  approbation 
of  the  profession. 

Physical  Treatment. — The  physical  treatment  includes,  as  its  most 
important  feature,  massage,  which  can  be  employed  in  all  cases,  even 
in  the  most  spastic  forms,  with  benefit  to  the  patient.  The  only  in- 
stances where  one  must  refrain  are  those  of  more  or  less  recent  ap- 
pendicitis or  peritoneal  inflammation.  The  patient  will  often  com- 
plain, during  the  first  session,  of  pain,  but  this  is  very  apt  to  be  due 
to  the  sensitive  abdominal  muscles.  If,  however,  a  markedly  local- 
ized spot  of  tenderness  is  found,  not  discovered  during  the  physical 
examination,  no  harm  will  be  done  by  light  massage  at  first,  gradually 
increasing  to  the  point  of  toleration.  The  methods  are  described  un- 
der Massage  (page  240),  and  every  physician  should  at  first  carry  out 
a  few  treatments  himself  before  turning  his  patient  over  to  a  trained 
masseur.  Vibration  massage  is  much  less  effective  than  manual,  but 
has  the  added  advantage  that  it  may  be  carried  out  at  home.  It  is  use- 
less to  attempt  this  form  of  treatment  unless  the  patient  will  consent 
to  six  weeks  of  its  employment,  and  then  it  should  be  continued  at 
short  intervals  for  a  year,  with  pauses  between,  which  add  efficacy  to 
its  results,  not  gained  if  the  process  is  continuous  without  pauses. 


418  DISEASES   OF   THE   DIGESTIVE   TRACT 

Faradization  for  periods  of  five  to  ten  minutes,  with  a  current  as 
strong  as  the  patient  will  stand,  can  also  be  employed,  either  with  both 
electrodes  on  the  abdomen  or  one  in  the  rectum,  and  is  particularly 
effective  in  neurasthenic  patients  with  sphincter  spasm  and  a  con- 
stantly filled  rectum.  Since  an  unpleasant  experience  with  a  galvanic 
current,  which  caused  superficial  burns,  its  employment  by  us  has 
been  given  up.  Exercises  and  gymnastics  prove  beneficial  when  there 
is  weakness  in  the  abdominal  muscles,  rowing  in  a  boat  or  a  rowing 
machine,  or  the  wall  weights,  being  best  adapted.  Change  of  posi- 
tion from  prone  to  sitting  without  aid  of  the  hands,  or  the  legs  raised 
upon  the  trunk,  also  aid.  The  neurasthenic  variety,  on  the  contrary, 
is  not  benefited  to  any  extent  by  violent  exercise,  and  after  months  of 
efforts  of  this  sort,  much  to  one's  chagrin,  when  a  patient  is  put  to 
bed  for  a  rest  diet  treatment,  stools  often  occur  after  a  time  with 
regularity,  and  the  physician  queries  his  judgment  in  not  employing 
this  method  sooner.  Cold  and  hot  water  play  their  part  in  the  treat- 
ment. When  there  is  a  spastic  condition  and  painful  sensations,  a 
hot  hip  bath  at  bedtime  soothes  and  relaxes  the  spasm  and  enables  the 
patient  to  sleep,  while  the  cold  spray  applied  to  the  abdomen  on  rising 
will  sometimes  relieve  the  most  obstinate  chronic  variety.  No  one 
claims  that  any  of  these  modes  of  treatment  increase  the  intestinal 
peristalsis,  but  they  do  improve  and  strengthen  the  abdominal  muscles, 
which  are  always  called  in  play  in  difficult  defecation.  As  has  been 
observed,  these  muscles  can  also  be  emploj'ed  with  much  greater  force 
if  the  patient  assumes  the  squatting  position  without  any  support  for 
the  buttocks.  Our  experience  does  not  extend  to  the  stripping  process 
for  removing  feces  from  the  rectum,  but  in  any  event  it  could  be  of 
aid  only  when  the  rectum  was  well  filled. 

Laxatives  have  long  been  avoided  by  the  more  intelligent  physicians 
in  the  treatment  of  constipation,  because  they  rarely  cure,  but  one  pill 
begets  another,  and  so  the  intestine  demands  its  bribe  before  it  will 
consent  to  work.  Still,  there  are  times  when  a  mild  laxative  is  neces- 
sary as  an  adjunct  to  dietetic  and  other  treatment,  but  such  a  one 
should  be  of  the  least  violent  character,  like  cascara  or  phenolphthalein, 
which,  taken  at  bedtime,  can  be  gradually  reduced  in  amount, 
or  periods  of  one  or  two  days  allowed  to  intervene  between  doses. 
Our  advice  usually  is,  if  no  stool  occurs  in  the  morning,  that  the  pa- 
tient take  a  dose  at  night;  this  insures  one  day's  freedom  from  their 
use,  and  often  the  nights  on  which  no  pill  is  taken  will  be  followed 
by  mornings  when  stool  occurs,  provided  the  other  means  are  being 
employed.     The  other  group  of  laxatives — the  salines,  sodium  phos- 


FUNCTIONAL  DISTURBANCES   OF   INTESTINAL   DIGESTION  419 

phate,  and  artificial  Carlsbad  salts,  etc. — are  employed  when  catarrhal 
conditions  are  present,  or  suspected  to  cause  the  constipation,  and 
prove  their  worth  by  a  return  to  natural  movements  after  a  period 
of  their  use.  In  the  ordinary  atonic  form,  however,  they  are  worse 
than  useless,  for  the  instant  they  are  dropped,  the  patient  is  as  bad 
or  worse  off  than  before.  For  the  most  aggravated  eases  a  course  of 
water  drinking  at  French  Lick,  Saratoga,  or  Bedford  Springs,  for 
those  who  can  afford  it,  is  desirable,  but,  as  said,  only  when  catarrhal 
conditions — or,  as  the  laity  often  have  it,  "liver  trouble" — are  pres- 
ent. Very  often  when  continuous  use  of  a  laxative  is  demanded,  one 
can  get  along  wdth  a  small  piece  of  rhubarb  root,  which  is  carried  in 
the  pocket,  and  a  fragment  bitten  off  and  eaten  two  or  three  times 
daily.  None  of  these  agencies,  as  far  as  our  observation  extends,  pro- 
duces griping,  and  the  only  objection  to  their  use  is  their  ineffective- 
ness upon  those  who  have  abused  cathartics  for  a  long  time.  For  the 
last  class  something  more  active  is  needed,  and  castor  oil  may  be  used 
at  rare  intervals  to  remove  fecal  masses  and  then  recourse  be  had  to 
the  milder  preparations,  but  continued  use  of  the  oil,  even  in  small 
doses,  undoubtedly  produces  a  catarrhal  condition  of  the  intestine 
from  its  irritation.  The  enormous  variety  of  laxatives  which  grace 
our  Pharmacopeia  has  sprung  from  the  desire  to  change  the  medicine 
frequently,  lest  the  patient  become  accustomed  to  any  one  kind,  which 
is  supposed  after  a  time  to  lose  its  activity  on  the  same  individual. 
Strange  to  say,  however,  we  are  told  many  times  by  patients  that  they 
have  used  a  small  amount  of  cascara  or  rhubarb  for  years,  never  in- 
creasing the  dose,  and  from  its  use  have  daily  movements.  In  such  a 
case  the  employment  of  another  kind  is  entirely  futile.  Then,  we 
have  those  instances  where  the  spastic  form  predominates  and  a  seda- 
tive is  demanded.  No  better  one  can  be  found  than  extractum  bella- 
donnae  in  suppositories  of  0.02  gram  (Y^  grain),  one  of  which  is  to  be 
inserted  nightly  until  such  time  as  free  movement  occurs — often  an 
astonishingly  short  time  if  the  form  is  purely  spastic.  As  it  is  some- 
times difficult  to  determine  exactly  whether  the  atonic  or  spastic  form 
predominates,  a  combination  of  cascara  and  belladonna,  like  the  fol- 
lowing, has  served  us  very  well : 

^     Extract!  belladonnae 0.2  or  3  grains 

Extract!  rhamni  purshianse 6.0  or  1%  drams 

Fiat  massa  et  divide  in  pilulas  XX. 
Sig. :     One  or  two  at  bedtime. 

These  pills  can  be  used  for  weeks  without  the  slightest  danger  from 
harm.     Hormonal,  a  substance  isolated  from  the  spleen  of  animals 


420  DISEASES   OP   THE   DIGESTIVE   TRACT 

killed  in  a  state  of  active  digestion,  has  been  used  for  chronic  consti- 
pation with  fair  results,  according  to  Glitsch.  One  intragluteal  in- 
jection of  20  c.c.  was  usually  sufficient  to  cause  daily  movements  for 
three  months  in  some  and  less  in  others,  but  the  effects  were  vastly  re- 
inforced by  a  second  injection,  without  harmful  results.  Still,  its  use 
is  not  wholly  without  dangers,  and  chills,  fever,  and  ominously  in- 
creased blood  pressure  have  been  reported  from  its  employment.  At 
best,  its  future  use  will  be  confined  to  relieving  the  bowels  after  opera- 
tions or  in  acute  fecal  obstructions. 

The  use  of  enemata  has  a  limited  field  in  treatment,  but  is  not  the 
universal  panacea  which  it  is  supposed  to  be,  and,  above  all,  such 
quantities  of  water  as  are  advised  to  be  given  with  the  "internal 
bath"  arrangement  still  advertised  in  some  of  our  best  magazines  are 
positively  dangerous.  When  the  rectum  is  packed  with  feces,  as  de- 
termined by  a  digital  examination,  a  cupful  of  water  with  soap  and 
glycerine  is  sufficient,  but  may  have  to  be  repeated.  When  the  ac- 
cumulation is  higher  up,  a  pint  usually  suffices  if  allowed  to  enter 
slowly  and  is  retained,  as  Boas  suggests,  over  night.  If  the  treatment 
is  to  be  continued  any  length  of  time,  only  salt  should  be  added,  for 
the  other  ingredients  commonly  employed — soap,  glycerine,  etc. — 
may  produce  too  much  irritation  and  a  catarrh  develop  from  a  purely 
functional  condition.  The  spastic  form  of  constipation  is  totally  un- 
fitted for  treatment  by  enema,  for  the  introduction  of  the  fluid  is  ac- 
companied by  pain  and  an  irresistible  tenesmus,  by  which  the  liquid 
is  forced  out;  in  fact,  this  is  a  diagnostic  point  in  this  state — inability 
of  the  patient's  lower  colon  to  retain  injected  fluid.  Following  the 
suggestion  of  Singer-Glaesner,  much  use  has  been  made  by  us  of 
cholalic  acid  as  an  ingredient  of  the  enemata,  mixed  with  sodium  bi- 
carbonate to  aid  solution.     The  proportion  is  as  follows : 

IJ     Colalin  3.0  or  45  grains 

Sodii   bicarbonatis    40.0  or  11,^  drams 

M.     Divide  in  chartulas  X. 

Sig. :     One  added  to  a  pint  of  water  for  injection. 

The  same  can  also  be  used  in  0.5-gram  suppositories,  though  not  as 
effective  as  by  injection.  Such  application  of  the  cholalic  acid  pro- 
duces prompt  contractions  of  the  colon,  as  is  shown  by  the  radiogram, 
and  stool  often  follows  in  twenty  to  thirty  minutes.  In  a  clinic  sought 
by  many  hundreds  of  constipated  women,  most  of  whom  have  borne 
a  dozen  children,  this  treatment  has  given  satisfaction.  The  oil  in- 
jections of  Fleiner  have  a  limited  field,  and  are  not  a  cure-all.  as  was 
supposed.     Its  employment  is  unquestionably  confined  to  the  spastic 


FUNCTIONAL  DISTURBANCES   OF   INTESTINAL.  DIGESTION  421 

variety  of  constipation  with  painful  sensations.  It  does  not  always 
soften  the  hardened  masses  of  feces,  and  many  times  patients  report 
its  discharge  the  next  morning  unchanged.  Furthermore,  it  has  been 
known,  after  a  long  use,  to  set  up  irritation  by  its  split  fatty  acids,  one 
of  the  features  that  makes  it  a  stimulant  to  the  colon. 

Regulation  of  habits  is  of  the  greatest  importance  as  an  adjuvant 
to  the  cure  of  constipation.  There  should  always  be  in  every  one's 
schedule  for  the  day  a  regular  time  for  stool,  and  at  this  period  an 
effort  should  always  be  made  for  its  accomplishment.  A  natural  call 
should  never  be  deferred  because,  curiously  enough,  it  is  not  apt  to 
be  repeated  until  the  next  day;  force  of  habit  in  regard  to  time  of 
defecation  is  an  unquestioned  one  and  cannot  be  explained.  Further- 
more, we  should  endeavor  to  remove  the  obsession  of  certain  patients 
that  all  feelings  of  discomfort,  like  fullness  of  the  head  and  inability 
to  apply  one's  self  mentally,  come  from  the  absence  of  a  movement 
on  that  particular  day.  In  this  respect  a  temporary  injunction  to 
forget  all  about  the  act  has  been  of  aid,  especially  to  those  who  employ 
mental  treatment.  As  this  condition  of  constipation  has  existed  in 
many  since  childhood,  no  effort  should  be  spared  to  induce  also  the 
child  to  have  a  regular  time  for  stool.  This  is  not  the  duty  particu- 
larly of  the  physician,  but  that  of  the  parent  or  teacher,  who  should  be 
advised  to  pursue  this  course. 

Special  conditions  accompanying  constipation  demand  appropriate 
treatment.  For  instance,  colics,  whether  due  to  habitual  constipation 
or,  as  often  happens,  to  lead  poisoning,  must  first  be  allayed  by  a 
hypodermic  of  morphine  sulphate  and  then  the  intestine  cleaned  out 
by  the  vigorous  use  of  castor  oil ;  then,  if  the  patient  is  subjected  to 
the  dangers  of  lead  poisoning,  magnesium  sulphate  or  a  weak  sul- 
phuric acid  lemonade  should  be  used  frequently  to  prevent  a  recur- 
rence of  the  attacks  of  pain.  ''Stoppage"  by  fecal  concrements  in 
the  aged  is  fairly  common,  and,  while  producing  none  of  the  symptoms 
which  so  ordinarily  accompany  kinks  or  twists  of  the  intestine,  may 
become  very  ominous  on  account  of  the  age  and  feebleness  of  the 
patient.  A  hypodermic  injection  of  1  mgm.  of  atropine  sulphate  and 
repeated  enemata  of  soap  and  water  are  often  necessary  to  remove 
the  obstacle. 

Operative  intervention  should  always  be  preceded  by  an  x-ray  ex- 
amination, because,  sad  to  say,  we  cannot  always  depend  on  other 
clinical  tests.  The  operative  procedures  have  been  discussed  in  gen- 
eral in  the  chapter  on  Treatment,  but  attention  is  called  here  to  a 
few   of  the   conditions   which   demand   the    surgeon's   aid.     Hirsch- 


422  DISEASES   OF   THE   DIGESTIVE   TRACT 

sprung 's  disease,  or  congenitally  dilated  colon,  manifests  itself 
largely,  of  course,  by  the  exaggerated  constipation,  and  so  far  has 
never  been  relieved  by  mechanical  or  medicinal  means.  The  implanta- 
tion of  the  ileum  in  the  sigmoid  by  Lane  has  given  only  partial  relief, 
and  later  he  suggested  and  carried  out,  in  conjunction  with  this  opera- 
tion, the  removal  of  the  cecum  and  half  of  the  transverse  colon.  Our 
experience  has  been  limited  to  one  case,  and  here,  much  to  our  surprise, 
the  expected  loose  movements  did  not  occur,  and,  other  than  the  fact 
that  the  constipation  was  overcome,  the  patient  underwent  no  detri- 
ment in  nutrition  or  general  conditions.  Wilm's  modifications,  by 
which  the  ileum  is  implanted  in  the  transverse  colon  and  then  the 
cecum  and  the  remainder  of  the  colon  adjacent  closed  off  by  mattress 
sutures,  has  proved  equally  efficacious  and  much  less  dangerous.  The 
suspension  and  fixation  of  the  cecum  where  typhlatony  (the  result  of  a 
large  accumulation  of  feces  in  the  cecum)  was  present,  has  proved 
very  satisfactory  where  the  constipation  is  caused  by  this  anomaly.  It 
must  be  emphasized  that  there  is  no  universal  treatment  for  all  forms 
of  constipation.  Every  patient  must  be  first  examined  carefully  to 
determine  with  which  peculiar  form — sphincter  spasm,  spastic  or 
atonic  colon,  or  adhesions — ^he  is  afflicted,  and  then  the  treatment  for 
this  particular  form  applied. 

PARASITIC  INTESTINAL  INDIGESTION. 

Parasitic  intestinal  indigestion  is  much  less  common  among  the 
better  classes  of  people  than  in  the  clinics.  Even  there,  where  a  large 
number  of  patients  are  treated,  careful  examination  of  the  feces 
wherever  abnormal  symptoms  are  present  will  show  that,  on  account 
of  the  strict  inspection  of  food  by  governmental  agencies,  parasites, 
particularly  tapeworm,  are  vastly  less  common.  Rarely  in  a  service 
of  three  months  will  more  than  two  or  three  cases  of  actual  parasites 
be  discovered. 

Tapeworms. — Tapeworms  may  or  may  not  cause  symptoms.  Very 
often  the  first  thing  which  attracts  the  attention  of  the  patient  is  the 
discharge  of  segments  or  fragments.  Nervous  individuals,  however, 
are  often  largely  distressed  by  these  discharges,  and  a  train  of  symp- 
toms are  aroused  which  are  largely  subjective.  There  is  loss  of  appe- 
tite, nausea,  desire  for  uncommon  articles — like  chalk,  earth,  etc. — 
eructations,  and  a  peculiar  bitter  taste  in  the  mouth  are  described ; 
creeping  sensations  in  the  abdomen  are  complained  of,  which  are  much 
worse  after  highly  seasoned  food  or  sour  articles  are  eaten ;  constipa- 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL  DIGESTION  423 

tion  or  diarrhea  may  be  present,  or  may  alternate,  with  the  passage 
of  much  mucus.  It  is  often  possible  that  here  a  confusion  with 
mucous  colitis  takes  place — headache,  confusion  of  thought,  giddiness, 
and  even  fainting  attacks  may  occur.  Emaciation  is  sometimes  pres- 
ent, in  spite  of  abundant  food,  and  there  may  be  unequal  pupils  and 
intermittent  rises  of  temperature,  as  well  as  mild  tetany.  These 
symptoms  are  ascribed  to  local  irritation  as  well  as  to  reflex  irrita- 
tion or  poisoning  from  substances  evolved  by  the  parasite.  The  latter 
possibility  has  been  thoroughly  investigated  by  Talquist,  who  found  in 
the  members  of  the  bothriocephalus  latus  group  a  substance  which  pos- 
sessed strong  hemolytic  power;  and,  in  truth,  the  broad  tapeworm 
produces  a  severe  and  sometimes  fatal  anemia,  which  has  all  of  the 
histological  earmarks  of  the  malignant  pernicious  variety.  The  other 
varieties  of  tapeworm  rarely  produce  excessive  anemia.  Many  of  the 
nervous  complaints  are  purely  neurasthenic,  for  patients  who  have 
not  a  sign  of  a  worm,  but  rather  mucous  colitis,  whose  broad,  flattened 
bands  of  mucus  closely  resemble  the  worm,  have  the  same  symptoms. 
The  diagnosis  should  never  be  allowed  to  rest  on  the  statement  of  the 
patient  or  his  symptoms,  but  the  fragments  must  be  found  and  identi- 
fied before  treatment  is  applied.  This  can  sometimes  be  accomplished 
in  a  busy  clinic  by  washing  out  the  colon  with  a  copious,  so-called  high 
injection,  applied  fractionally;  rarely,  if  fragments  are  present,  will 
they  fail  to  be  washed  out.  The  detection  of  Charcot-Leyden  crys- 
tals and  eosinophiles,  either  in  the  stool  or  the  increase  of  the  latter 
in  the  blood,  cannot  be  utilized  for  positive  diagnosis. 

The  expulsion  of  the  tapeworm  can  be  best  accomplished  by  making 
the  patient  fast  on  the  day  before  the  destruction  of  the  parasite  is 
attempted,  during  which  one  or  two  doses  of  a  laxative  (sodium  phos- 
phate or  magnesium  sulphate)  are  taken.  On  the  morning  of  the  ef- 
fort the  patient  is  to  remain  in  bed,  and  take  oleoresina  aspidii,  8 
grams  (2  drams)  in  four  doses  in  capsules  at  half-hour  intervals,  and 
black  coffee  if  nausea  is  produced ;  one  hour  after  the  last  dose,  if  the 
worm  is  not  expelled,  a  good  dose  of  Epsom  or  Glauber 's  salts  is  taken. 
The  patient  must  be  asked  to  save  with  great  care  the  discha;rges  after 
the  treatment,  put  them  through  cheesecloth,  wash  them  well  with 
water,  and  transfer  to  a  fruit  jar,  to  be  brought  to  the  clinic,  for,  un- 
less after  a  careful  examination  the  head  is  discovered,  the  whole  proc- 
ess will  have  to  be  gone  through  later,  as  the  presumption  always  is 
that  the  head  has  not  been  removed.  One's  success  is  largely  de- 
pendent on  the  quality  of  the  preparation  of  aspidium,  for  one  does 
not  dare  to  take  chances  with  a  much  increased  dose  in  expectation 


424  DISEASES   OF   THE   DIGESTIVE   TRACT 

that  the  preparation  is  old,  for,  if  fresh  and  the  regular  dose  is  em- 
ployed, it  may  sometimes  cause  decided  poisonous  symptoms. 
Pelletierine  tannate,  0.3  gram  (5  grains)  in  capsule,  and  filmaron — or, 
better,  filmaron  oil — a  10  per  cent  solution  of  the  active  principle  of 
aspidium  in  castor  oil,  put  up  conveniently  in  5-gram  capsules  (0.5  gram 
filmaron),  two  of  which  are  to  be  taken  at  half-hour  intervals,  followed 
two  hours  later  by  a  full  dose  of  castor  oil,  are  very  good  substitutes 
for  the  crude  drug,  but  are  equally  dangerous  in  large  doses,  and  their 
cost  is  prohibitive  in  a  clinic. 

Round  Worms. — Round  worms  are,  of  course,  most  common  in  chil- 
dren, and  cause  the  mothers  much  distress,  since  all  the  ailments  of 
childhood  are  attributed  to  their  malign  influence,  as  were  all  diseases 
formerly  in  Hahnemann's  mind  attributable  to  scabies.  Still,  as  men- 
tioned, they  have  been  found  by  us  in  the  stomach  of  a  young  man  at 
autopsy,  where  they  often  migrate,  and  are  either  vomited  or  make  their 
way  to  the  glottis,  producing  choking  symptoms,  or  escape  from  the 
nose  or  mouth.  In  the  intestine  they  have  been  known  to  form  a  ball, 
which  was  perceptible  through  the  abdominal  wall  as  a  small  tumor. 
Much  oftener,  however,  they  may  make  their  way  to  the  common  he- 
patic duct,  which  they  may  close  completely. 

Symptoms. — The  symptoms  which  they  cause  are  described  as  nau- 
sea, distaste  for  food,  pain  in  the  abdomen,  constipation  or  diarrhea,  ac- 
companied by  discharge  of  mucus,  twitching  of  the  muscles,  grinding  of 
the  teeth,  outcries  at  night  (to  the  mother  the  most  suggestive  feature), 
emaciation,  and  actual  convulsions.  Of  course,  we  must  bear  in  mind 
that  all  these  symptoms  may  occur  in  children  without  any  evidence  of 
worms,  and  twice  in  our  experience  an  emetic  after  a  convulsion  has 
brought  to  light,  in  children  under  2  years  of  age,  in  one  case  bologna 
sausage  and  in  the  other  fried  potatoes  instead  of  the  expected  worms. 
Here,  too,  a  secondary  action  of  the  secretion  of  the  worms  may  be  re- 
sponsible for  the  nervous  symptoms.  As  these  worms  are  often  passed 
per  anum,  the  diagnosis  of  their  actual  presence  in  the  intestine  is  not 
difficult,  and  in  their  absence  the  examination  of  the  stools  will  show  the 
presence  of  the  easily  recognized  eggs. 

Their  removal  is  usually  accomplished  by  santonin  given  in  0.03- 
gram  (i/^-grain)  doses  after  meals  for  two  or  three  days,  followed  by  a 
laxative,  either  calomel  or  magnesium  sulphate,  which  can  be  dissolved 
in  birch  beer  for  children  on  account  of  its  unpleasant  ta.ste.  Castor 
oil  should  never  be  employed  because  the  drug  is  readily  soluble  in  it, 
and  may  produce  pofsonous  effects,  or  the  santonin  and  the  calomel  may 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL  DIGESTION  425 

be  combined,  as  in  the  following  prescription  from  the  Manual  of  the 
Pharmacopeia  (A.M. A.)  : 

IJ     Santonini, 

Hydrargyri  chloridi  mitis,  aa 6.5  or  8  grains 

Sacchari  lactis 1.0  or  15  grains 

M.     Divide  in  chartulas  X. 

Sig. :     One  after  meals  three  times  daily. 

Oxyuris  vermieularis,  or  threadworm,  is  the  most  harmless  of  the 
group,  and  annoys  chiefly  by  causing  itching  of  the  anus  and  neigh- 
boring parts.  At  operation  for  appendicitis  a  mass  of  them  is  often 
found  in  this  appendage,  and  here  they  probably  grow  to  wander  into 
the  whole  colon.  That  they  are  sometimes  an  exciting  cause  of  the 
inflamed  appendix  must  be  conceded,  but  the  event  must  be  uncommon, 
comparing  the  frequency  of  the  presence  of  the  threadworm  with  the 
rarity  of  appendicitis.  It  is  practically  useless  to  attempt  to  drive  out 
these  pests  by  medicine  given  by  mouth,  but  high  injections  of  vinegar 
and  water  or  a  tablespoonful  of  fluid  extract  of  quassia  to  a  pint  of 
water,  injected  several  nights  in  succession,  and  preceded  by  a  soap 
and  water  injection  if  the  lower  bowel  is  filled  with  fecal  matter,  are 
usually  effective. 

The  necator  Americanus,  or  hookworm,  a  branch  of  the  ankylostoma 
duodenale  family,  has  caused  much  interest  in  our  country  because  of 
the  intense  anemia  which  it  causes  when  once  well  established  in  the 
duodenum.  It  enters  the  body  of  man,  not  only  through  the  mouth, 
but  through  the  unbroken  skin,  and  from  the  carelessness  of  the  poorer 
dwellers  of  the  South  with  regard  to  outhouses,  or  rather  the  lack  of 
them,  and  the  custom  of  many  of  these  people  to  go  barefooted,  their 
distribution  was  well  spread  until  the  governmental  health  forces  and 
the  philanthropy  of  the  Rockefeller  fund  began  to  cheek  their  growth. 
Dr.  Stiles'  lectures  and  pictures  before  the  laity  and  his  traveling 
clinics,  held  through  the  region  most  affected,  are  a  tower  of  strength 
for  the  eradication  of  the  hookworm.  After  the  infection  and  previous 
to  the  appearance  of  the  marked  anemia,  some  time  may  elapse,  dur- 
ing which  the  symptoms  are  chiefly  loss  of  appetite,  nausea,  heartburn, 
and  vomiting,  together  with  either  constipation  or  diarrhea.  The 
abdominal  symptoms  become  much  more  distinctive  with  the  increas- 
ing pallor,  the  abdomen  is  more  distended,  and  here  and  there  points 
can  be  found  which  are  tender  to  pressure.  The  liquid  stools  contain 
much  food  residue,  mucus,  and  blood.  Eosinophile  leucocytes  are 
found  commonly  with  the  feces,  and  eosinophilia  of  the  blood  is  much 
more  marked  than  with  any  other  parasite.     The  blood  in  the  feces  is 


426  DISEASES  OF   THE  DIGESTIVE   TRACT 

not  only  due  to  the  inflammatory  disturbance,  but  comes  from  the 
wounds  of  the  intestine  produced  by  the  bites  of  the  hookworm.  The 
anemia  which  accompanies  the  presence  of  these  parasites  in  the  in- 
testine is  secondary,  but  with  an  occasional  change  to  the  most  malig- 
nant, pernicious  type.  While  it  is  the  poorer  classes  of  the  South  that 
propagate  these  hookworm  infections,  many  others  may  become  hosts, 
for,  during  our  teaching  at  the  University  of  Texas,  students  were 
often  found  who  harbored  these  pests.  The  eggs  are  easily  recognized, 
even  when  the  worms  are  not  found. 

Treatment. — The  treatment,  which  was  introduced  by  the-  Govern- 
ment through  the  infected  regions,  was  the  use  of  2-4  grams  (i/^-l 
dram)  of  thymol,  given  in  four  doses  in  capsules  during  the  day,  and 
followed  by  a  tablespoonful  of  magnesium  sulphate  in  water ;  in  other 
words,  for  a  few  cents  many  a  one  has  been  freed  from  his  enemy, 
while  the  action  of  the  Government,  reinforced  by  private  aid,  has  been 
to  arouse  the  exposed  individual  from  his  indifference  to  this  disease. 

INTESTINAL  INDIGESTION  IN  BASEDOW'S  DISEASE. 

Intestinal  indigestion  in  Basedow's  disease  has  come  to  the  atten- 
tion of  every  one  who  has  had  occasion  to  treat  this  peculiar  pathologic 
condition.  It  is  also  associated  with  Addison's  disease,  which  one 
meets  with  vastly  less  often.  In  uremia  and  sepsis,  as  well  as  in  other 
infectious  diseases — pneumonia,  malaria,  measles,  etc. — there  is  marked 
diarrhea,  due,  as  is  supposed,  to  the  irritation  of  the  intestinal  raucous 
membrane  by  toxic  substances  reaching  it  through  the  blood.  There 
exists  marked  transudation,  but  very  little  change  in  the  mucous  sur- 
face of  the  bowel.  Mucus  and  food  fragments  are  also  rare  in  the 
stool.  "With  Basedow's  disease  the  diarrhea  is  different.  Though  it 
may  be  aroused  by  the  irritation  of  a  secretion  of  the  overactive  thyroid, 
there  are  many  food  remnants  in  the  stool,  which  indicate  clearly  that 
an  intestinal  indigestion,  in  the  sense  which  we  employ,  exists.  The 
diarrheas  of  Basedow's  disease  (those  of  Addison's  have  never  come  to 
our  attention)  are  periodic,  as  if  at  times  the  gland  reached  the  acme 
of  its  output  of  the  deleterious  secretion.  They  are  very  virulent,  last- 
ing for  days  or  a  week,  and  very  difficult  to  control.  The  most  char- 
acteristic feature  of  the  stool,  in  many  cases,  is  the  fat,  which  usually 
comprises  33-77  per  cent  of  that  taken  as  food,  but  usually  in  well- 
split  form,  so  that  no  impairment  of  the  pancreas  can  be  demonstrated. 
The  stools  number  from  two  to  ten  daily,  and  many  fatty  acid  needles 
are  found,  but  no  meat  fibers,  even  if  the  amount  of  the  latter  taken 


FUNCTIONAIi  DISTURBANCES  OP  INTESTINAL  DIGESTION  427 

by  mouth  is  very  much  increased,  nor  does  mucus  form  any  considerable 
constituent  of  the  feces.  In  a  case  for  a  long  time  under  our  observa- 
tion, whose  stool  was  examined  frequently,  there  was  no  predominance 
of  fat  and  no  other  changes  than  one  would  expect  from  a  hurried 
peristalsis — a  moderate  amount  of  all  the  food  ingredients  and  no  mucus. 
Still,  A.  Schmidt  would  have  us  believe  that  in  some  way  the  pancreas 
is  affected  because  there  is  often  associated  an  alimentary  glycosuria. 
Treatment. — The  treatment  is  also  as  unsatisfactory  as  the  etiology 
of  the  disease.  When  fatty  stools  occur,  neither  restriction  of  this  con- 
stituent of  food  nor  pankreon  makes  any  change  in  the  amount  ex- 
creted. Falta  found  that  the  x-ray  treatment  applied  to  the  thyroid 
caused  both  the  glycosuria  and  the  fatty  diarrhea  to  cease.  Eppinger 
and  Von  Noorden,  Jr.,  employed  rectal  injections  of  adrenalin,  using 
30  drops  of  the  1 :1,000  solution  in  300  c.c.  of  water,  on  the  theory  that 
the  increased  peristalsis  was  due  to  exaggerated  vagotonus,  and  ob- 
tained excellent  results.  As  these  attacks  of  diarrhea  are  periodic 
and  self-limited,  one  should  not  put  too  much  dependence  on  any  mode 
of  treatment  other  than  the  removal  of  the  thyroid  or  means  to  check 
its  increased  secretion. 

INTESTINAL  INDIGESTION  FROM  DEGENERATION. 

Intestinal  indigestion  as  a  result  of  degeneration  of  the  mesenteric 
glands  and  amyloid  disease  of  the  mucous  membrane  are  both  accom- 
panied by  great  distention  of  the  abdomen,  while  the  patient  emaciates 
rapidly.  The  stools  in  these  cases  are  mushy  and  not  watery,  light- 
yellow  in  color,  and  rich  in  fat,  of  which  at  least  20-30  per  cent  are 
lost.  The  feces  are  acid  in  reaction,  and  contain,  apart  from  the  fat, 
very  few  muscle  fibers  and  no  starch.  As  the  fat  is  usually  well  split, 
the  failure  is  one  of  absorption,  and  is  of  minor  importance  compared 
with  the  greater  one  of  tuberculosis  of  the  glands  involved,  but  is  a 
severe  hindrance  to  the  proper  nourishment  of  the  victim.  Amyloid 
disease  springs  readily  from  other  intestinal  disease,  particularly  tu- 
berculosis, and  produces  excessive  watery  stools,  with  all  varieties  of 
food  remnants,  many  of  them  visible  to  the  naked  eye,  and  with  a 
marked  tendency  to  putrefaction.  Again,  one  may  observe  instances 
of  marked  impairment  of  fat  absorption  and  many  muscle  fibers, 
whether  due  to  a  coincident  disease  of  the  pancreas  or  to  increased 
motility  cannot  be  told.  The  enlarged  amyloid  liver  often  accompan- 
ies this  intestinal  condition  and  should  always  be  sought  under  the 
right  costal  border,  if  it  cannot  be  readily  seen  as  it  frequently  can. 


428  DISEASES   OF   THE   DIGESTIVE   TRACT 

NERVOUS  DIARRHEA. 

Nervous  diarrhea  is  characterized  by  the  absolute  failure  of  any 
objective  cause  and  its  occurrence  on  any  occasion  which  overexcites  the 
patient.  Of  course,  there  is  an  increased  peristalsis,  but  whether  the 
stimulus  is  reflex  or  passes  directly  from  the  brain  cannot  be  told. 
Various  causes  have  been  given  for  its  occurrence — motility  and  se- 
cretion neuroses — but  the  truth  apparently  is  that  both  processes  are 
involved.  The  most  readily  recognized  clinical  type  of  this  disease  is 
diarrhea  which  arises  from  anxiety.  Young  surgeons  performing  their 
first  operation,  students  just  before  a  severe  examination,  and  the 
Arabian  Nights  tell  many  a  tale  of  fright  as  its  cause,  so  that  it  must 
have  been  a  well-recognized  difficulty  in  earlier  days.  There  are  two 
or  three  loose  movements,  perhaps  with  some  tenesmus,  and  then 
things  go  as  before.  In  those  who  from  childhood  up  have  had  this 
weakness  it  takes  but  little  to  arouse  an  attack.  A  former  patient  of 
ours,  of  the  old  regime,  could  never  receive  a  telegram  without  this 
effect,  because  it  might  contain  bad  news  and  she  would  hesitate  to 
open  it,  and  she  could  not  remember  a  time  in  her  life  when  violent 
emotions,  particularly  worry,  did  not  produce  the  same  result.  In  a 
coaching  trip  through  Scotland  and  Ireland  a  lady  of  the  party  would 
almost  invariably  hold  up  the  vehicle  a  few  minutes  after  it  was  ready 
to  start  while  she  sought  a  lavatory,  because  another  could  not  be 
reached  easily  during  the  period  of  the  trip,  reminding  me  of  Noth- 
nagel's  patient,  who  began  to  feel  an  intense  desire  for  stool  as  soon  as 
he  found  he  was  far  from  a  water  closet.  Indeed,  this  intense  nervous 
tenesmus  is  usually  the  cause  of  the  diarrhea.  There  are  also  those 
who  are  readily  affected  by  being  chilled  without  actually  acquiring  a 
coryza  or  bronchitis,  and  respond  with  frequent  movements,  while  at 
other  times  the  stool  is  perfectly  normal,  so  that,  to  avoid  this,  such 
persons  wear  a  warm  abdominal  band  as  a  preventive.  There  may 
also  occur  a  copious  discharge  of  weakly  alkaline  fluid  at  times,  usually 
arousing  a  patient  from  sleep,  without  a  vestige  of  fecal  matter,  much 
like  the  so-called  "water  brash"  of  the  stomach  and  esophagus,  which 
is  probably  almost  w^holly  intestinal  transudate. 

The  most  characteristic  feature  of  these  diarrheas  is  the  suddenness 
with  which  they  occur.  The  patient  is  feeling  perfectly  well,  when 
perhaps,  with  some  rumbling  in  the  abdomen  and  possibly  discomfort 
in  the  same  region,  but  no  pain,  there  is  a  tenesmus,  a  passage  of  some 
gas,  and  then  the  watery  stools,  when  the  affair  is  over,  much  like  a 
thunderstorm,  and  the  patient  may  be  free  for  weeks  or  months.     All 


FUNCTIONAL   DISTURBANCES   OF   INTESTINAL  DIGESTION  429 

efforts  to  discover  an  article  of  food  which  caused  the  attack  is  in  vain. 
It  occurs  after  eating  at  the  best  hotels  as  readily  as  after  a  meal  at 
a  night  lunch  counter.  With  some  a  headache  of  the  unilateral  va- 
riety may  precede,  and  Moebius  thinks  it  often  replaces  the  persistent 
vomiting  in  migraine.  No  disturbance  of  health  other  than  this  is 
noted — the  patient  has  a  good  appetite  and  eats  what  he  pleases  with- 
out the  slightest  tendency  to  produce  an  attack. 

The  feces  in  all  cases  of  this  character,  chiefly  those  of  more  or  less 
duration,  where  it  has  been  our  opportunity  to  examine  them  have  had 
the  ordinary  food  remnants — fats,  muscle  fibers,  and  starch — in  equal 
proportions,  and  but  little  in  excess  of  what  are  usually  found  in 
health ;  there  has  been  no  mucus.  Of  course,  in  the  very  acute  attacks, 
which  are  over  after  three  or  four  movements,  the  feces  have  never  been 
examined,  and  we  are  all  equally  ignorant  as  to  their  character.  Pre- 
sumably because  of  the  copiousness  of  the  stools,  the  whole  tract  must 
be  emptied  and  the  feces  contain  abundant  gross  and  microscopic  food 
remnants.  "Whether  we  are  dealing  actually  with  a  nervous  diarrhea 
can  be  told  only  by  examination  of  the  stools  in  the  intervals,  when  a 
catarrhal  condition  will  be  readily  recognized,  or,  if  the  attacks  occur, 
as  they  sometimes  do,  daily  at  certain  periods  (early  morning  hours, 
after  dinner,  etc.),  the  absence  of  mucus  or  any  marked  presence  of 
food  fragments,  or  predominance  of  one  over  the  other,  will  identify 
it  as  the  nervous  form. 

Treatment. — The  treatment  is  extremely  unsatisfactory  because  the 
disease,  unlike  other  intestinal  disorders,  is  entirely,  according  to  our 
observation,  uninfluenced  by  diet.  A  hot  sitz-bath  before  going  to 
bed  will  aid  when  the  call  comes  at  3  or  4  a.  m.,  and  a  glass  of 
claret  or  a  cup  of  strong  tea  at  bedtime  may  avail.  Medicines 
are  of  little  value,  though  validol  or  anesthesin  will  sometimes  check 
the  oversusceptibility.  In  obstinate  cases  a  cupful  of  starch  clys- 
ter, with  20  drops  of  tinctura  opii,  at  bedtime,  will  hold  the  bowels 
quiet  until  morning,  but  opiates  must  never  be  given  by  mouth 
for  fear  of  the  habit.  When  the  attack  comes  on  during  dinner,  in 
the  presence  of  the  family  or  guests,  at  regular  intervals,  if  the  patient 
eat  alone  in  his  room,  it  will  often  break  up  the  sequence.  A  com- 
plete change  of  scene  will  sometimes  check  the  habit,  one  is  almost 
inclined  to  say,  because  it  follows  no  laws  of  disease,  and  the  Great 
White  Way  of  New  York,  with  champagne  and  ices,  long  forbidden, 
effected  a  cure  in  one  of  our  most  obstinate  cases. 


CHAPTER  XVI 

INFLAMMATORY  DISEASES  OF  THE  INTESTINE 

As  with  the  stomach,  we  differentiate  carefully  between  mere  im- 
paired functions  of  the  intestine  and  impaired  functions  dependent 
on  anatomical  changes.  For  instance,  we  may  have  a  diarrhea,  as 
we  have  seen,  without  any  discernible  anatomical  cause,  or  we  may 
have  one  dependent  on  a  tubercular  or  dysenteric  ulcer.  Hence  it  is 
perfectly  useless  to  say  that  a  patient  is  suffering  from  diarrhea. 
Stagnation  of  blood  in  the  abdominal  organs  also  leads  to  impaired 
function  as  well  as  to  actual  inflammatory  disease,  but  it  would  not  be 
correct  to  call  all  intestinal  indigestions  associated  with  cardiac  leak- 
age or  hepatic  obstruction  "stasis  catarrhs"  when  no  inflammation 
was  present.  Then,  too,  we  must  try  to  separate  the  symptoms  due 
to  intestinal  catarrh,  as  it  is  called,  from  nervous  ones.  This  word 
catarrh  makes  an  excellent  designation  for  a  condition  where  the 
superficial  epithelial  layer  is  affected,  with  hyperemia  of  the  blood 
vessels,  whereby  an  excessive  secretion  of  mucus  takes  place.  It  does 
not  cover  the  term  enteritis,  of  which  it  is  only  a  part,  as  the  latter 
includes  inflammation  also  of  submucous  and  interstitial  tissue.  It 
has  also  been  demonstrated  where  any  considerable  amount  of  mucus 
is  found  in  the  stool  that  true  enteritis  (with  the  exception  of  mucous 
colitis)  exists  which  has  passed  beyond  the  mucous  layer.  Another 
point  which  causes  great  difficulty  is  the  determination  of  the  site  of 
the  inflammation.  When  confined  to  the  cecum,  appendix,  sigmoid, 
and  rectum,  physical  signs  will  usually  fix  its  site,  but  elsewhere,  from 
the  stool  alone,  our  only  means  of  its  establishment,  it  is  a  difficult 
matter,  in  spite  of  Nothnagel's  efforts  to  establish  some  rules  for  our 
aid.  As  a  rule,  from  fecal  examination  we  may  learn  that  the  in- 
flammatory^ process  is  confined  to  the  large  .or  small  intestine,  but 
farther  we  may  not  go.  As  far  as  cause  is  concerned,  it  is  well  to 
divide,  as  has  always  been  done,  these  catarrhs  into  the  primary  and 
secondary.  The  former  includes  those  arising  per  se  and  the  latter 
those  which  are  the  outcome  of  some  other  disease,  like  tuberculosis, 
dysentery,  carcinoma,  stenosis,  or  typhoid.  This  separation  is  also  of 
great  value  clinically,  because  we  must  apply  our  therapeutic  efforts 

430 


INFLAMMATORY   DISEASES   OF   THE   INTESTINE  431 

to  the  primary  disease  rather  than  to  the  catarrh.  Again,  it  is  rare 
that  the  catarrh  originated  where  it  is  found.  When  in  the  small 
intestine,  it  is  apt  to  come  from  the  stomach,  or,  rather,  its  imper- 
fectly digested  food  may  arouse  it ;  and  when  in  the  colon,  it  has  often 
been  aroused  by  putrefaction  or  fermentation  of  food  which  should 
have  been  digested  and  absorbed  in  the  small  intestine. 

GASTROENTERITIS. 

Gastroenteritis,  or  gastroenterocolitis,  is  a  term  which  includes  an 
inflammation  of  the  entire  digestive  tract,  a  condition  which  we  some- 
times find.  Its  cause,  while  considered  by  the  laity  as  some  article 
of  food  or  drink,  is  more  often  infectious  or  toxic.  Of  the  former  we 
have  the  infections  peculiar  to  the  tract — that  of  the  colon  bacillus,  of 
the  paratyphoid  and  the  ameba — or  the  infection  may  be  general,  with 
only  a  participation  on  the  part  of  the  tract,  like  influenza,  pneu- 
monia, and  sepsis.  These  attacks  are  much  more  common  in  summer 
than  in  winter,  but  whether  the  conditions  are  favorable  for  a  more 
vigorous  growth  of  bacteria  in  the  food  at  this  season,  or  whether 
the  digestive  juices  of  the  patient  are  less  effective  in  destroying  those 
germs  entering  the  tract,  cannot  be  told.  A  large  number  of  chemical 
substances  also  may  excite  a  catarrh,  such  as  lead,  mercury,  and  cop- 
per in  workmen  in  these  metals,  or  excessive  use  of  alcohol,  tobacco, 
or  condiments.  ^Medicaments,  too — salvarsan,  mercury,  and  sodium 
cacodylate — used  hypodermatically  or  intravenously,  may  be  elimi- 
nated into  the  canal  and  cause  catarrhs.  These  inflammations  are  also 
aroused  by  nephritis,  uremia,  and  extensive  burns.  Among  the  rarer 
causes  are  a  stenosis  due  to  malignant  disease,  enteroliths  or  gall- 
stones causing  obstruction  in  the  intestine,  or  what  is  sometimes  known 
as  intestinal  sand  or  gravel. 

Symptoms. — The  symptoms  usually  begin  in  perfect  health,  and 
the  stomach  may  or  may  not  be  affected.  As  a  rule,  one  profuse  at- 
tack of  vomiting  ends  the  participation  of  the  stomach,  colicky  pains 
intervene,  and  at  first  scanty  semisolid  or  solid  stools  occur,  followed 
shortly  by  liquid  ones,  with  much  gas  and  tenesmus.  The  patient 
feels  very  ill,  becomes  pale,  and  his  nose  is  pinched  as  in  collapse; 
there  may  be  chills,  and  the  temperature  often  rises  to  100-104  de- 
grees; the  movements  increase  until  they  number  five  to  fifteen  dur- 
ing the  day,  and,  while  the  thirst  is  intense  from  the  loss  of  so  much 
fluid,  the  patient  fears  to  drink  because  it  increases  his  pain  and  num- 
ber of  movements;  in  a  very  few  days  the  patient  becomes  emaciated. 


432  DISEASES   OP   THE   DIGESTIVE   TRACT 

the  stools  consist  largely  of  water  and  are  odorless,  while  the  urine 
is  almost  suppressed ;  pains  in  the  muscles  and  cramps  in  the  calves 
intervene,  the  temperature  sinks,  and  the  pulse  become  rapid  and 
weak;  the  skin  assumes  a  marked  pallor,  except  that  of  the  extremi- 
ties, which  may  become  bluish ;  cold  sweats  occur,  and  still  the  patient 
may  recover — a  fatal  termination  is  rare.  Usually,  however,  the  at- 
tack is  much  lighter;  the  stools  diminish  after  three  days;  some  food 
may  be  taken  without  their  increase,  and  after  a  considerable  period 
convalescence  is  established,  but  great  care  must  be  taken  for  a  long 
time  with  the  diet,  or  a  recurrence  of  the  diarrhea  takes  place,  and 
after  one  or  two  repetitions  the  disease  becomes  chronic.  Constipa- 
tion is  also  liable  to  follow  for  a  short  time,  and,  as  stated,  must  not 
be  treated  with  laxatives.  The  change  in  the  general  condition  de- 
pends largely  on  the  build  and  constitution  of  the  individual.  Weak, 
undernourished  persons  are  vastly  more  affected  than  the  stronger, 
though  the  violence  of  the  attack  may  be  the  same.  Some,  too,  suffer 
from  dyspnea  and  palpitation  of  the  heart,  which  has  been  variously 
ascribed  to  the  pressure  of  the  diaphragm  on  the  heart  and  lungs, 
driven  up  by  the  distention  of  the  intestines  by  gas,  while  others  at- 
tribute it  to  autointoxication. 

Cerebral  irritations  (delirium  and  convulsions)  are  chiefly  confined 
to  children.  The  fever  has  not  been  so  common  in  our  experience, 
perhaps  because  the  eases  which  were  under  our  care  were  not  so  severe. 
The  abdominal  distress  is  of  two  kinds — a  feeling  of  fullness  and 
tension,  and  the  repeatedly  occurring  cramps,  during  which  the  pa- 
tient presses  his  hands  against  his  abdomen  and  draws  up  his  knees. 
As,  after  a  series  of  these  cramps,  a  stool  follows,  they  are  probably 
due  to  violent  peristalsis  and  spasm  of  the  intestine.  They  may  occur 
anywhere  in  the  abdomen,  or  are  more  often  confined  to  the  left  iliac 
region,  and,  if  the  rectum  is  involved,  there  is  a  painful  tenesmus  after 
stool  and  a  sense  of  incomplete  defecation.  On  inspection  of  the 
abdomen,  no  marked  distention  can  be  discovered,  nor  does  percus- 
sion show  that  much  gas  is  present.  It  is  only  the  fact  that  bor- 
borygmi  are  common  and  flatus  is  continually  discharging,  often  with 
a  fragment  of  feces,  that  we  are  assured  that  gas  is  present  in  any 
amount.  During  the  colicky  attacks  there  is  an  involuntary  retrac- 
tion of  the  abdomen,  so  that  it  may  look  quite  flat,  and  at  the  same  time, 
if  the  walls  are  thin  and  there  is  a  diastasis  of  the  recti,  the  exaggerated 
peristalsis  of  the  intestines  can  be  seen.  In  some  portions  of  the  ab- 
domen this  is  more  marked  than  others,  and  a  tap  with  the  fingers  will 
elicit  succussion,  showing  an  accumulation  of  gas  and  fluid.     Palpa- 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  433 

tion  is  usually  unpleasant  to  the  patient,  if  not  actually  painful;  in 
fact,  here  and  there  can  be  found  points  whose  manipulation  causes 
exquisite  pain,  if  one  can  judge  from  the  countenance  of  the  patient. 
Occasionally,  too,  when  the  walls  are  thin,  one  can  discover  the  con- 
tracted colon  as  a  cord,  but  this  spasm  is  not  confined  to  one  part,  but 
changes  its  position,  or,  rather,  different  parts  of  the  colon  are  thrown 
into  spasm  at  various  times.  The  examination  of  the  feces  is  of  great 
importance,  not  only  from  a  diagnostic  point  of  view,  but  from  a  prog- 
nostic, because  until  the  stools  have  returned  to  the  normal  in  fre- 
quency and  character  (absence  of  mucus)  we  dare  not  pronounce  our 
patient  cured  and  allow  him  to  go  back  to  his  indiscriminate  diet. 
From  the  patient  himself  we  can  obtain  only  the  statement  that  the 
stools  are  liquid  and  ascertain  their  number  daily.  In  fact,  after  the 
first  stool  they  are  ejected  with  great  force  (in  spurts),  are  of  a  dirty- 
brown  color,  and  have  a  very  foul  odor.  Later  the  character  will 
change  in  accordance  with  the  diet.  If  milk,  oatmeal  and  barley  gruels, 
and  carbohydrates  (ground  toasted  bread)  are  given,  they  become 
yellow,  have  a  sour  odor  and  acid  reaction,  and  indicate  clearly  that 
fermentative  processes  are  going  on  in  the  intestine.  It  is  not  un- 
usual during  the  first  few  days  for  the  stools  to  have  a  golden-yellow 
color  or  a  tinge  of  green,  because  the  bile  pigment  is  hurried  along 
without  an  opportunity  for  reduction.  Often  the  stools  have  a  jelly- 
like consistency  on  account  of  the  large  amount  of  mucus,  existing 
chiefly  in  masses,  from  the  beginning  of  the  tract  (duodenum  or  jeju- 
num). Later  the  fermentative  character  of  the  stool  disappears,  it 
becomes  colorless,  and  has  a  neutral  reaction.  During  the  early  period, 
before  the  intestine  is  cleared  out,  the  naked  eye  will  plainly  discover 
fragments  of  connective  tissue,  with  masses  of  muscle  fiber  embedded, 
which  appear  as  small  brown  specks,  and  groups  of  potato  cells. 
After  the  patient  is  on  the  rigid  diet,  the  microscope  will  still  show 
starch  granules,  masses  of  casein,  groups  of  split  fats,  and,  if  broths 
are  used,  sharp-angled  muscle  fibers.  From  this  it  can  be  determined 
that  the  inflammation  extends  even  to  the  duodenum,  and  that  all  the 
ingredients  of  food  are  affected,  which  means  that  either  an  exag- 
gerated peristalsis  or  impaired  digestive  juices  are  responsible,  but,  as 
diastase  and  trypsin  have  both  been  found  in  the  discharges,  the 
former  supposition  is  probably  the  true  one.  Of  the  real  products  of 
inflammation,  the  mucus  is  the  most  important.  It  may  be  distributed 
through  the  feces,  so  that  they  will  quiver  like  a  mass  of  jelly,  or  it 
may  be  in  lumps  (sago  grains),  or  in  shreds  that  float  on  top  of  the 
liquid  stool.     The  fragments  may  be  glassy,  stained  yellow,  brown, 


434  DISEASES   OF   THE   DIGESTIVE   TRACT 

or  green  with  hydrobilirubin  or  bilirubin,  or  red  with  blood.  They 
are  either  clear  or  cloudy  from  an  admixture  of  detritus  from  epi- 
thelial cells  and  fats.  When  mucus  is  absent,  we  are  not  dealing  with 
an  enteritis,  but  with  an  indigestion.  The  microscope  shows  only  a 
scanty  display  of  epithelial  cells  in  the  mucus,  shriveled,  round,  with 
vacuoles  and  erythrocytes,  if  from  the  colon,  and  only  nuclei  and 
abundant  bacteria  if  from  the  small  intestine.  Leucocytes  are  lacking, 
and  erythrocytes  are  found  only  in  the  mucus.  While  the  stomach 
was  always  supposed  to  be  involved  in  these  attacks,  recent  statistics 
show  that  in  not  more  than  half  of  the  cases  do  we  have  vomiting.  The 
stomach,  however,  is  very  promptly  restored  to  its  normal  condition 
long  before  the  inflammation  has  left  the  intestine.  The  urine  is  al- 
ways very  scanty,  contains  a  large  amount  of  urobilin  and  indican, 
often  a  trace  of  albumin,  and,  what  is  more  significant  to  the  patient, 
usually  deposits  a  heavy  layer  of  urates.  The  course  of  the  disease 
is  generally  restricted  to  eight  to  fourteen  days. 

ENTEROCOLITIS. 

Chronic  enterocolitis  may  arise  from  an  acute  attack  where  the  con- 
valescence is  long  delayed,  or  after  several  acute  attacks,  or  sometimes 
occurs  where  no  acute  attack — at  least  in  the  memory  of  the  patient — 
has  ever  taken  place.  In  the  latter  case,  however,  there  has  been 
complaint  for  years  of  abdominal  discomfort,  consisting  of  distention, 
rumbling  of  the  intestines,  and  a  tendency  to  looseness  of  the  bowels 
on  any  indiscretion  of  diet,  such  as  the  abundant  use  of  potatoes,  fruit, 
milk,  or  ice  cream.  It  would  seem  that  intestinal  indigestion,  as  de- 
scribed before,  exists,  with  an  occasional  exacerbation,  which  ap- 
proaches the  catarrhal  stage.  These  people,  too,  after  a  time  acquire 
what  may  be  termed  intestinal  hypochondriasis,  much  as  the  consti- 
pated do,  and  every  act  of  their  lives  is  considered  only  with  refer- 
ence to  its  effect  on  the  intestinal  condition.  There  is  little  or  no 
pain,  except  perhaps  after  taking  food,  which  seems  to  incite  peristal- 
sis, and  after  stool,  when  there  is  apparently  a  temporary  colon  spasm. 
The  patient's  weight  and  general  condition  seem  to  be  uninfluenced, 
unless  the  small  intestine  is  especially  affected,  together  with  pan- 
creatic achylia,  so  that  there  is  a  great  loss  of  nutritive  elements  (a 
rare  condition),  though  a  peculiar  pallor  may  arise  after  long  con- 
tinuance of  the  disease,  which  reminds  one  of  pernicious  anemia.  In 
a  careful  study  of  eleven  cases  of  pernicious  anemia,  which  was  pub- 
lished by  us,  no  features  were  found  in  the  stools  which  could  not  be 


INFLAMMATORY   DISEASES   OF   THE   INTESTINE  435 

discovered  in  other  intestinal  catarrhs  where  no  anemia  existed,  other 
than  the  excessive  hydrobilirubin,  and,  as  instances  of  the  former  out- 
number the  latter  enormously,  there  is  apparently  no  causative  rela- 
tion. From  the  objective  examination,  one  can  learn  but  little.  There 
is  never  any  abdominal  resistance,  and  only  occasionally  can  one  feel 
and  hear  a  gush  of  intestinal  contents  through  some  temporarily  con- 
tracted portion  of  the  tract.  Rarely  is  the  colon  sensitive  to  pressure, 
but  its  cordlike  contraction  is  less  common  than  in  the  acute  form. 

The  excessive  number  of  movements — or,  perhaps,  it  would  be  better 
to  say  the  irregularity  of  the  stools — forms  the  chief  complaint  of  the 
victim  of  chronic  enterocolitis.  When  both  large  and  small  intestine 
are  equally  involved,  and  we  are  not  dealing  with  an  enteritis  or  a 
colitis,  they  vary  from  one  to  many  mushy  stools  daily.  Then  there 
may  come  a  period  when  the  stools  are  normal  for  a  short  time,  or 
under  the  use  of  astringents,  which  every  doctor  prescribes,  may  be- 
come even  hard  or  "constipated,"  as  the  patient  describes  it,  but  the 
mucus  still  persists.  Then  succeeds  another  period,  without  any 
kno^;!!  cause,  of  loose  movements.  The  customary  alternation  between 
constipation  and  diarrhea,  as  is  found  in  pure  colitis,  does  not  occur 
here.  The  stools  are  perfectly  painless,  unlike  the  acute  form,  nor 
does  tenesmus  follow.  The  feces  have  much  the  same  characteristics 
as  in  the  acute  form,  though  erythrocytes  are  much  less  commonly  at- 
tached to  the  mucus,  and  leucocytes  almost  never  occur.  In  our  ex- 
perience the  digestion  and  absorption  of  meat  and  fat  seem  to  suffer 
much  more  than  that  of  starch,  and  square-cornered  muscle  fibers  and 
soap  and  fatty  acid  needles  will  be  found  vastly  oftener  than  the  starch 
granules.  Mucus  is  always  present,  and  its  absence  excludes,  as  be- 
fore stated,  a  deep-seated  inflammatory  process.  The  fragments  are 
often  hard  to  find  because  so  intimately  mixed  with  the  feces,  but,  if 
several  fecal  masses  be  allowed  to  stand  in  water  over  night,  the  next 
morning  one  can  fish  out  specimens  free  from  fecal  matter  and  finely 
adapted  to  microscopic  examination.  This  mucus  exists  in  two  forms 
— small  fragments,  looking  moth  eaten  and  containing  cell  nuclei,  and 
larger  and  more  stable  looking  patches,  which  are  covered  with  rolled 
up  epithelial  cells,  whose  nuclei  can  usually  be  brought  out  by  stain- 
ing. Both  varieties  are  colorless,  or  a  dirty-gray,  when  separated  from 
fecal  matter  in  this  way,  and  it  seems  assured  that  the  former  come 
from  the  small  intestine,  though  A.  Schmidt  speaks  of  bilirubin  color- 
ing as  a  prerequisite.  Usually,  on  account  of  the  excess  of  mucus,  the 
feces  are  dark-brown  in  color,  have  a  putrid  odor,  and  a  strong  alka- 
line reaction. 


436  DISEASES   OF   THE   DIGESTIVE   TRACT 

The  duration  of  the  disease  can  generally  be  placed  as  a  lifetime, 
for  the  victim  has  usually  suffered  for  years  from  the  diarrhea  when 
he  comes  to  the  physician ;  in  fact,  few  patients  know  when  it  did  be- 
gin. Under  the  physician's  care  temporary  relief  is  obtained,  and  he 
discharges  the  patient  as  cured,  only  to  learn  that  a  colleague  is 
treating  him  for  the  same  disorder^ — as  a  patient  once  said  to  us  *'I 
wish  I  could  remember  the  names  of  the  doctors  who  have  cured  me 
of  this  complaint." 

The  diagnosis  often  requires  some  thought  because  of  the  similarity 
to  other  abdominal  lesions.  For  instance,  the  diarrhea  of  typhoid 
might  prove  confusing,  but  the  latter  has  a  longer  onset,  more  con- 
tinuous fever,  rose  spots,  enlarged  spleen,  and  gives  an  agglutination 
test.  With  appendicitis  there  may  be  confusion,  but  the  markedly 
local  tenderness  and  pain,  spasm  of  the  rectus,  mass,  and  higher  tem- 
perature in  the  latter,  usually  protect  us.  The  colicky  pains  before 
each  discharge  and  tenesmus  after,  usually  decide  in  favor  of  entero- 
colitis. In  the  chronic  form  the  question  is  largely,  are  we  dealing 
with  a  disease  that  involves  the  whole  intestinal  tract, — the  large 
or  small  intestine.  The  presence  of  numerous  food  particles  means 
that  the  higher  portion  of  the  tract  is  most  involved,  while  washing 
out  the  colon  with  slightly  alkaline  water  will  bring  to  light  large 
quantities  of  mucus  if  that  portion  is  affected,  or  the  use  of  the  recto- 
scope  will  accomplish  the  same  result. 

Treatment  of  Acute  Form. — The  treatment  of  the  acute  form  con- 
sists in  freeing  the  tract  from  noxious  elements — bacteria,  improper 
food,  or  chemical  substances — by  a  good  laxative,  and  then  maintain- 
ing the  canal  in  a  state  of  rest  until  the  inflammation  has  subsided. 
The  first  object,  if  nature  has  not  already  accomplished  it,  is  secured, 
as  explained,  by  calomel,  0.06  gram  (1  grain)  in  divided  doses,  or 
castor  oil  (a  tablespoonful).  The  laity  employ  this  treatment  almost 
without  the  advice  of  the  physician,  and  never  have  unfortunate  re- 
sults but  once  from  its  use  come  under  our  observation,  and  then  the 
disease  was  appendicitis  and  not  enterocolitis.  Directly  after  the 
cleansing  process,  the  sooner  the  intestine  is  quieted,  the  better,  and 
this  can  be  accomplished  by  tinctura  opii  deodorati  15-20  drops,  or, 
what  has  seemed  more  suitable  to  me  since  the  ipecac  has  an  influence  on 
the  intestine,  tinctura  ipecacuanhae  et  opii  (liquid  Dover's  powder)  in 
the  same  doses.  On  account  of  the  diarrhea,  suppositories  are  out  of 
the  question,  but,  if  the  patient  vomits,  a  hypodermic  injection  of  mor- 
phine sulphate,  0.015  gram  (I/4  grain)  will  have  to  be  given.  It  is 
useless  to  mince  matters  with  small  doses,  for  one  generous  dose  will 


INFLAMMATORY   DISEASES   OF   THE   INTESTINE  437 

accomplish  more  than  a  series  of  small  ones.  The  results  of  .either 
method  of  application  are  very  favorable — the  tenesmus  and  colics 
cease,  and  the  movements  become  less  numerous.  No  substitute  has 
ever  been  found  for  opium  to  control  these  symptoms,  and  an  excess 
of  the  medicament,  followed  by  a  cessation  of  movements  for  a  few 
days,  can  do  no  harm. 

The  diet  for  the  first  twenty-four  to  thirty -six  hours  should  be  dis- 
tinguished chiefly  for  its  scantiness.  Complete  abstinence  from  both 
food  and  drink  is  best  if  one  can  induce  the  patient  to  submit,  but 
from  fear  of  too  rapid  loss  of  strength,  or,  as  some  insist,  from  an 
increase  of  his  discomfort  by  total  deprivation,  it  may  be  found  de- 
sirable to  offer  a  demulcent  drink,  like  strained  barley  or  flour  gruel, 
to  which  some  sugar  may  be  added ;  for,  while  it  has  been  found  that 
the  ability  of  the  duodenum  to  furnish  a  ferment  which  will  split 
milk  sugar  is  restricted,  the  ordinary  cane  sugar  is  easily  taken  care  of. 
These  gruels  do  not  add  so  much  by  furnishing  nutrition  in  an  as- 
similable form,  since  the  calories  in  a  bowlful  would  be  but  few  un- 
less strongly  fortified  with  sugar,  as  they  do  by  soothing  the  inflamed 
surface  of  the  digestive  tract.  Milk  is  not  advisable  at  first,  for,  as 
explained,  the  sugar  of  milk  is  intractable  to  the  lowered  power  of 
the  digestive  juices,  and,  even  if  boiled,  it  increases  the  diarrhea.  The 
next  step  after  the  violence  of  the  attack  has  somewhat  subsided — say, 
to  three  or  four  stools  daily — ^is  the  introduction  of  broths  made  of 
beef,  mutton,  or  chicken,  freed  wholly  from  fat  by  skimming  the  stock, 
to  which  well-cooked  rice,  barley,  or  sago,  rubbed  through  a  fine  sieve, 
or  flour  may  be  added,  and  a  slice  of  toast  with  fresh  butter  may  be 
allowed.  Should  the  patient  continue  to  improve,  we  may  next  (usu- 
ally after  a  week)  add  a  well-beaten  egg  cooked  in  the  broth,  some 
oysters  lightly  boiled  in  their  own  juice  (panned),  and  chicken  or 
squab.  For  drinks,  albumin  M'ater  (white  of  an  egg  to  a  cup  of 
water)  and  cold  weak  tea,  A\'ith  sugar  and  a  teaspoonful  of  brandy, 
works  well  by  quenching  the  thirst,  and  does  not  increase  the  diarrhea. 
Arranged  in  a  schedule,  these  suggestions  read  as  follows : 

DIET  LIST  IN   ACUTE  ENTEROCOLITIS. 

7  A.  M. — A  glass  of  albumin  water,  well  sweetened ;  after  three  days, 
a  bowl  of  strained  oatmeal  gruel,  -svith  butter  and  sugar ;  after  a  week 
a  dropped  egg  on  toast,  with  unsalted  butter. 

10  A.  M. — A  cup  of  cocoa  made  with  water  and  taken  warm,  not  hot ; 
after  three  days,  chicken  broth  containing  well-cooked  rice  or  barley ; 
after  a  week,  a  slice  of  chicken. 


438  DISEASES   OF   THE   DIGESTIVE   TRACT 

1  P.  M, — A  cup  of  cold  tea,  with  sugar  and  a  teaspoonful  of  brandy ; 
after  three  days,  a  sago  gruel  (sago  to  be  left  in  water  over  night  and 
then  thoroughly  cooked  and  rubbed  through  a  fine  sieve),  which  may 
be  sweetened;  after  a  week,  a  cup  of  hot  bouillon,  with  a  beaten  egg 
cooked  in  it. 

4  p.  M. — A  glass  of  sugar  water,  flavored  with  a  little  vanilla ;  after 
three  days,  a  cup  of  mutton  broth,  with  rice ;  after  a  week,  a  half  dozen 
cooked  oysters. 

7  p.  M. — ^A  glass  of  of  rice  water,  made  as  described,  by  cooking  the 
rice  and  then  sieving,  or  rice  flour  may  be  used  instead;  after  three 
days,  tapioca  or  arrowroot  gruel;  after  a  week,  a  broiled  squab,  with 
toast 

During  the  night  the  patient  can  usually  be  made  contented  with  oc- 
casional sips  of  cold  tea. 

This  variety  of  food  is  necessary,  for  the  patient's  appetite  is  im- 
paired, and  the  dreaded  monotony  of  the  usual  diet  makes  futile  all 
efforts  to  arouse  it.  An  early  experience  of  ours  with  typhoid,  when 
a  glass  of  milk  was  brought  us  every  four  hours  and  nothing  else 
for  three  long  weeks,  has  led  us  to  attempt  variety  in  a  diet,  which  is 
often  contemptuously  referred  to  by  patients  as  one  made  up  of 
"slops."  If  after  a  week  the  opium  treatment  has  failed  to  check 
the  number  of  discharges,  it  is  desirable  to  try  some  of  the  astringents, 
and  here,  with  the  pharmacopeial  preparations  and  those  boomed  by 
proprietary  interests,  one  is  often  at  a  loss  on  account  of  their  multi- 
plicity. The  lime  salts  make  an  excellent  astringent  in  this  case,  and 
a  combination  of  the  three  best  known  may  be  employed  to  advantage, 
as  follows: 

IJ     Calcii  carbonatis  prsecipitati, 

Calcii  phosphatis, 

Calcii  subsalicylatis,  aa   10.0  or  5^  ounce 

M.     Fac  in  capsulas  XX. 
Sig. :     One  three  times  daily. 

The  only  complication  which  needs  attention  in  acute  enterocolitis 
is  collapse,  and  that  can  usually  be  checked  by  hypodermic  injections 
of  camphor  and  oil,  most  conveniently  prepared  in  ampules,  of  which 
the  contents  of  one  is  to  be  injected  according  to  the  needs  of  the  pa- 
tient. 

Treatment  of  Chronic  Form. — The  treatment  of  chronic  entero- 
colitis is  one  of  the  most  difficult  problems  presented  to  a  physician. 
In  the  first  place,  the  doctor  is  very  fortunate  if  he  is  not  the  heir  to 
the  failures  of  at  least  half  a  dozen  practitioners  on  the  same  patient, 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  439 

who  can  hardly  be  expected  to  be  in  a  hopeful  frame  of  mind.  Then, 
every  one  of  the  half  dozen  has  had  his  own  individual  ideas  on  the 
diet  to  be  employed  in  intestinal  catarrh,  which,  unfortunately  for  the 
patient,  vary  extremely,  and  are  based  often  on  the  idiosyncrasies  of 
the  last  patient  the  physician  happened  to  treat.  Nor  is  this  surpris- 
ing when  such  diverse  views  are  expressed  by  the  leaders  of  our  branch 
of  healing — Boas,  Wegele,  Rodari,  Strauss,  etc.;  hence  every  patient 
has  notions  of  his  or  her  own  about  diet,  and  has  a  long  list  of  articles 
of  food  which,  in  her  or  his  case  at  least,  increases  the  diarrhea.  We 
are,  therefore,  forced  to  make  a  break  at  once  with  such  notions  or 
to  eliminate  them  gradually.  As  in  the  acute  form,  the  diet  plays  the 
most  important  part,  and,  since  the  discharges  are  watery  and  in- 
creased in  number,  and  the  articles  of  food  are  wretchedly  utilized, 
all  we  can  hope  to  do  is  to  see  that  all  foods  are  reduced  to  their  finest 
practicable  form — mashed  vegetables,  minced  fish  and  meat,  gelatine, 
cup  custards,  omelets,  and  jellies  free  from  seeds  and  skins.  Then, 
after  installing  this  minutely  divided  form  of  diet,  we  can  only  watch 
the  stool  and  note  what  the  results  are.  Usually  starch  is  admirably 
taken  care  of,  while  meat  and  fat  still  persist  in  the  stool  in  generous 
quantities.  Strange  to  say,  we  cannot  adapt  the  diet  wholly  to  the 
diarrhea,  but  must  make  it  suitable  for  catarrh  of  the  intestine,  and, 
as  either  confined  or  loose  bowels  may  alternate,  we  must  adjust  the 
diet  to  meet  these  conditions,  still  bearing  in  mind  the  irritability  of 
the  lumen  of  the  colon.  This  can  be  done  by  inserting  or  withdraw- 
ing certain  articles  of  food  which,  while  equally  digestible,  have  a  laxa- 
tive or  non-laxative  effect,  from  a  general  scheme.  For  instance,  where 
two  or  three  loose  movements  with  abundant  mucus  occur  a  day,  we 
employ  the  following: 

DIET   LIST   IN    CHRONIC   ENTEROCOLITIS. 

Breakfast. — Cocoa,  with  a  saccharine  tablet ;  one  or  two  eggs  cooked 
in  any  form  except  fried ;  toast  and  fresh  butter. 

11  A.  M. — A  couple  of  small  cheese  sandwiches  made  of  stale  bread 
and  cream  cheese,  or  plain  crackers  may  be  employed;  no  saltines. 

Dinner. — Soup  or  broth  containing  rice,  barley,  or  crushed  oats 
(chicken  broth,  Scotch  broth,  etc.)  ;  picked  fish,  or  minced  meats  or 
croquettes ;  rice  or  grits ;  vermicelli  or  macaroni ;  toast,  with  plenty  of 
butter ;  a  wineglassful  of  homemade  elderberry  wine  or  vermuth. 

4  p.  M. — Same  as  11  a.  m. 

Supper. — Chicken  broth  or  Scotch  broth,  minced  meat  on  toast,  jelly, 
plain  crackers  and  butter. 


440  DISEASES   OF   THE   DIGESTIVE   TRACT 

Great  care  must  be  taken  to  avoid  all  vegetables  rich  in  cellulose — 
spinach,  celery,  turnip,  radishes,  salads,  uncooked  fruit,  nuts,  rye 
or  brown  bread,  and  jams  in  which  the  fruit  seeds  are  still  present. 
The  only  difficulty  with  such  one-sided  diets  is  that  the  patients  soon 
tire  of  them  and  fail  to  take  enough  to  maintain  their  caloric  de- 
mand. In  such  cases  it  may  be  well  to  allow  a  departure  occasionally, 
where  the  sufferer  is  permitted  to  choose  his  greatest  favorite  in  the 
gastronomic  line — a  bit  of  "high"  game,  an  ice  cream,  fresh  fruit,  or 
an  indulgence  in  champagne,  all  articles  which  increase  morvements, 
but  in  the  isolated  instance  often  have  no  effect.  Its  continuance, 
however,  soon  begins  to  be  marked  by  increasing  movements  and  more 
* '  slime, "  as  it  is  called  by  the  laity.  The  constant  tendency  to  under- 
nourishment must  be  overcome  by  increasing  the  number  and  amount 
of  the  lunches,  as  we  will  term  them,  or  we  may  introduce  our  ground 
toasted  bread  into  all  liquids. 

The  medicinal  treatment,  which  begins  with  efforts  to  correct  the 
gastric  digestion  if  at  fault — achylia  by  hydrochloric  acid  and  hyper- 
secretion by  atropine — after  which  we  may  proceed  to  the  correction 
of  the  difficulty  for  which  we  were  consulted — frequent  movements. 
As  we  are  dealing  with  a  chronic  affair,  w^hich  at  the  best  will  take 
months  to  get  under  control,  opiates  are  out  of  the  question.  Then, 
too,  bismuth  crystals  can  be  seen  so  often  in  the  stools,  with  their 
sharp-angled  outline,  that  one  wonders  whether  they  do  not  irritate 
instead  of  soothe,  and  the  bismuth  salts  (outside  of  the  subsalicylate) 
have  been  practically  cut  out  of  our  armamentarium  for  controlling  the 
inflammation  of  the  intestine.  Pankreon  is  admirably  adapted  to  this 
catarrhal  condition  because  usually  associated  with  impaired  pan- 
creatic secretion,  and,  second,  since  it  contains  a  little  tannin,  it  makes 
an  excellent  astringent.  One  often  notices  a  diminution  of  the  number 
of  discharges;  in  fact,  some  patients  complain  of  constipation  on  its 
use.  Other  tannin  preparations,  like  tannalbin  or  tannigen,  in  0.2- 
0.5-gram  (3-8-grain)  doses  every  three  to  four  hours,  may  be  em- 
ployed to  advantage,  and,  while  some  may  think  that  these  modern 
products  of  pharmacy  have  no  advantage  over  the  old-fashioned  rha- 
tany  and  catechu,  yet  the  former  unquestionably  bring  about  their 
results  with  less  disturbance  than  the  latter.  Mineral  waters,  apart 
from  those  containing  lime  and  alum,  are  of  little  avail.  The  Bedford 
alum  spring  waters  have  proved  very  efficacious  in  checking  these  long 
continued  diarrheas  when  associated,  of  course,  with  the  appropriate 
diet ;  while,  if  one  can  take  the  cure  at  the  springs,  all  the  additional 
advantages,  often  mentioned,  will  accrue  to  the  benefit  of  the  patient. 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  441 

Colon  washings,  when  much  tenesmus  is  present,  aid  very  materially 
in  promoting  the  comfort  of  the  patient,  and  may  hasten  the  progress 
to  health,  if  a  mild  substance  be  added  to  the  wash  water,  like  Carlsbad 
salts  (a  teaspoonful  to  a  quart).  Not  much  can  be  expected,  however, 
with  reference  to  a  restoration  to  normal  conditions  by  these  means. 
On  the  contrary,  in  our  experience  nitrate  of  silver,  tannin,  dermatol, 
etc.,  when  added  to  the  wash  water,  have  made  the  catarrh  distinctly 
worse,  and  Boas  warns  against  the  use  of  the  strong  astringents.  A 
hot  hip  bath  at  bedtime  is  advantageous,  but  whether  the  abdominal 
band  is  of  any  distinct  use  is  difficult  to  say ;  at  least  the  patient  derives 
comfort  from  its  use,  and  no  harm  can  arise  from  it. 

Now,  while  we  have  to  consider  the  catarrh  of  the  intestine  as  a 
whole,  and  probably  in  a  large  percentage  of  those  affected  the  entire 
tract  is  involved,  still  enough  instances  of  strictly  localized  inflamma- 
tion, confined  either  to  the  large  or  small  intestine,  exist,  so  that  we 
must  consider  each  severally. 

ENTERITIS. 

Enteritis,  or  inflammation  of  the  small  intestine,  exists  largely  by 
grace  of  the  fact  that  time  had  not  been  given  the  individual  affected 
to  have  an  extension  into  the  colon;  in  other  words,  either  death  or 
recovery  stayed  the  progress  of  the  disease  at  the  ileocecal  valve,  for 
otherwise  an  extension  seems  certain.  The  purest  cases  of  enteritis  are 
those  accompanying  severe  burns  or  uremia  where  the  upper  jejunum 
and  duodenum  are  involved,  and  phosphorus  and  arsenical  poisoning 
where  the  inflammation  comes  through  from  the  stomach,  which  is  also 
involved.  It  seems  pretty  clear  that  only  one  of  the  criteria  which 
Nothnagel  established  for  the  differentiation  of  enteritis  from  entero- 
colitis will  stand  the  test  of  time,  and  that  is  the  absence  of  frequent 
movements.  This  has  long  been  known  to  us  from  the  fact  that  many 
a  typhoid  has  passed  through  its  entire  course  without  inducing  di- 
arrhea, yet  the  lesion  is  in  Peyer's  patches.  In  this  connection  we 
must  take  into  account  the  instances  of  icterus  catarrhalis,  or,  better, 
acute  cholangitis,  which  often  comes  in  after  a  disturbance  of  the 
stomach  or  a  diarrhea.  In  the  few  cases  where  an  autopsy  has  been 
had,  a  plug  of  mucus  has  been  found  in  the  choledochus,  and  this  has 
been  regarded  as  a  cause  of  the  stagnation  of  bile,  but  the  cause  may 
be  equally  as  well  an  invasion  of  the  duct  by  bacteria  from  the  duo- 
denum and  damage  of  the  liver  cells  by  their  toxins.  There  is  no 
fever,  but  patients  complain  of  symptoms  relating  to  their  jaundice, 


442  DISEASES   OF   THE   DIGESTIVE   TRACT 

itching,  great  mental  depression,  inability  to  think  clearly,  as  well  as — 
and  here  is  the  significant  part — discomfort  in  the  region  of  the  duo- 
denum, fullness  and  pressure  after  eating,  and  localized  rumbling  and 
gushes  of  material  in  the  region  of  the  epigastrium.  Frequent  dis- 
charges occur  during  the  early  part  of  the  attack  before  the  jaundice 
appears;  and  one  has  much  less  opportunity  to  examine  the  stool,  as 
the  patient's  attention  is  seldom  called  to  his  own  condition  until 
jaundice  appears;  then,  unfortunately,  one  finds  only  the  stools  of 
icterus  when  the  evidences  of  duodenitis  have  disappeared.  The  di- 
arrheas which  accompany  uremia,  severe  burns,  sepsis,  and- arsenical 
or  phosphorus  poisoning  have  much  the  same  characteristics.  There 
is  always  an  intermediate  hemorrhagic  or  ulcerous  enteritis,  and  the 
onset  is  very  sudden ;  the  stools  are  watery  and  occur  with  astonishing 
frequency ;  the  patients  complain  of  abdominal  pains,  and  it  sometimes 
happens  that  the  central  portion  of  the  abdomen  above  the  navel  be- 
comes locally  distended,  indicating  involvement  of  the  peritoneum. 
The  examination  of  the  stools  shows  no  coarse  mucous  fragments,  but 
narrow  worm-eaten  shreds  are  numerous.  Food  remnants  are  visible 
to  the  naked  eye.  Unchanged  bile  pigment  is  found  in  the  beginning 
of  the  attack,  but  blood  is  common  throughout,  and  can  usually  be 
recognized  readily  by  the  color  (chocolate-brown)  of  the  stool,  while 
the  reaction  is  alkaline. 

Treatment. — The  treatment  can  offer  but  little  aid  for  this  condi- 
tion. Its  violence  and  short  duration  before  either  recovery  or  death 
takes  place  gives  but  little  time  for  medical  arts.  Opium  to  quiet  the 
intestine  and  demulcent  soups  seem  all  that  can  be  employed.  When 
we  are  inclined  to  make  a  diagnosis  of  chronic  enteritis  apart  from  its 
association  with  colitis,  more  careful  consideration  will  probably  show 
that  it  is  one  of  the  various  forms  of  intestinal  indigestion  and  not  a 
true,  enteritis. 

TYPHLITIS. 

Typhlitis,  or  cecum  mobile,  has  again  begun  to  arouse  the  interest 
of  physicians  because,  while,  in  the  glow  of  enthusiasm  associated  with 
the  discovery  of  appendicitis  and  the  brilliant  results  accompanying 
the  removal  of  the  appendix,  we  were,  so  to  speak,  swept  off  our  feet 
and  willing  to  ascribe  every  discomfort  located  in  the  right  iliac  fossa 
to  the  appendix,  yet  many  of  us,  who  faithfully  attended  operations  of 
our  own  eases,  began  to  have  a  marked  suspicion,  when  apparently 
healthy  appendices  were  removed  and  subsequently  the  patient  was 
no  better,  that  something  more  was  at  fault  for  the  pain  than  the  inno- 


INFLAMMATORY   DISEASES   OF   THE   INTESTINE  443 

cent  looking  appendix.  Even  those  surgeons,  be  it  said  to  their  credit, 
who  were  removing  most  of  the  appendices  began  the  investigation, 
and  their  wonderful  facilities  soon  put  us  back  on  solid  ground.  There 
is,  and  always  has  been,  a  typical  perityphlitis  and  paratyphlitis  by 
peritoneal  invasion  in  w^hich  the  appendix  may  not  be  disturbed  in  any 
way  and  remain  perfectly  healthy.  Then,  too,  a  peculiarly  long  cecum 
was  often  found,  and  one  which  from  its  long  mesentery  was  given 
unusual  freedom  of  movement,  by  which  it  could  be  pushed  to  the  left 
of  the  median  line  or  even  up  under  the  liver.  Its  accompanying 
symptoms  are  occasional  attacks  of  colic,  with  no  rise  of  temperature 
but  abdominal  distentions,  nausea,  and  constipation.  Thus  the  res- 
toration of  a  term  and  the  acknowledgment  of  a  condition,  which  we 
older  practitioners  were  allowed  to  recognize,  but  of  which  we  have 
been  deprived  since  everything  in  that  region  was  appendicitis,  not 
typhlitis,  seem  fully  justified. 

The  anatomical  reasons,  apart  from  the  weakened  musculature,  for 
these  low-grade  inflammations  and  adhesions  seem  to  be  an  unusually 
long  mesentery,  low  position  and  free  movement  of  the  cecum,  added  to 
the  long  delay  of  the  fecal  matter  in  this  portion  of  the  tract,  which 
makes  it  the  site  of  choice  for  most  ulcerative  processes  (dysentery, 
tuberculosis,  etc.).  How  much  adhesions  have  to  do  with  the  dilated 
cecum,  and  whether  they  arise  from  an  antecedent  ulcer  caused  by  stag- 
nating fecal  contents,  food  detritus  (bone  splinters,  egg  shells,  etc.), 
or  masses  of  round  worms,  cannot  yet  be  told.  At  least  in  a  case  of 
which  we  made  a  careful  study,  and  which  was  operated,  adhesions 
were  the  chief  feature  in  continuing  the  condition,  though  their  cause 
remained  unknown;  at  any  rate,  the  appendix  was  above  reproach. 
The  radiogram  is  here  reproduced  (Fig.  81). 

Symptoms. — The  symptoms  of  typhlitis  must  necessarily  vary  ac- 
cording to  whether  it  remains  uncomplicated  or  the  inflammatory 
process  extends  to  the  appendix,  the  entire  colon,  or  the  ileum.  Fur- 
thermore, it  is  often  difficult  to  differentiate  sharply  the  acute  from 
the  chronic  form,  or,  rather,  to  learn  whether  acute  attacks  have  ever 
taken  place;  at  least,  the  attacks,  if  acute,  must  have  been  of  very 
short  duration  and  have  caused  no  great  disturbance  of  the  general 
health.  The  most  important  feature  is  the  colicky  attacks,  which  begin 
in  the  right  iliac  region  without  the  slightest  warning  and  extend  in 
the  direction  of  the  navel  or  gallbladder.  These  pains  may  be  so 
slight  that  only  when  forced  movements  are  made,  like  bending,  do 
they  stab  one,  or  may  be  so  severe  that  a  cold  sweat  comes  upon  the  pa- 
tient's  brow,  and  he  must  leave  whatever  he  is  doing  until  the  parox- 


444 


DISEASES   OF   THE   DIGESTIVE   TRACT 


ysm  is  over,  while  some  vomit  and  rarely  faint.     After  an  acute  exacer- 
bation, there  is  a  dull  pain  in  the  same  region  for  some  time.     When 


Fig.  81. — Radiogram  of  cecum  mobile   (bisnuitli  ingested).      (Collection  of  Dr.  Arial  W. 

George.) 

the  attack  comes  on  before  dawn,  as  it  sometimes  does,  the  patient  may 
be  induced  to  remain  in  bed,  but,  if  at  work,  can  rarely  be  persuaded 
to  give  it  up,  for  after  the  attack  of  pain  he  declares  himself,  apart 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  445 

from  soreness,  as  well  as  ever.  Taking  cold,  allowing  the  bowels  to  be- 
come confined,  and  some  article  of  food  are  at  times  accused  by  the 
victim  of  the  attack,  and,  then  again,  he  can  give  no  explanation  for 
it.  When  chronic,  the  pain  follows  no  law  whatever.  A  patient  of 
ours,  working  for  a  large  express  company  on  the  floor  of  the  dis- 
tributing room,  was  allowed  his  few  minutes  for  an  attack  of  pain  and 
then  returned  to  work,  much  as  if  he  had  gone  to  lunch;  this  con- 
tinued for  three  or  four  years  until  he  was  operated  on.  Nothing 
noticeable  is  found  on  inspection  of  the  abdomen,  though,  in  one  case 
under  our  observation,  pulsation  of  the  right  iliac  artery  was  readily 
seen,  while  that  of  the  left  could  not  be  detected  by  the  eye ;  this  was, 
undoubtedly,  purely  accidental.  A  feature  of  diagnostic  importance, 
however,  is  the  absence  of  the  right  rectal  spasm,  the  ' '  defense  muscu- 
laire,"  so  common  in  an  inflamed  appendix.  Palpation  during  an 
attack  of  pain  is  likely  to  be  painful,  but  not  to  the  extent  that  the 
patient  makes  a  wry  face  and  pushes  away  the  examiner's  hand.  Dur- 
ing the  interval  the  whole  region  can  usually  be  felt  without  pain,  but 
deep  pressure  with  two  fingers  over  McBurney's  point  will  produce 
it.  This  sensitive  zone,  however,  is  not  nearly  as  closely  defined  as 
with  an  inflamed  appendix,  and  tenderness  can  be  elicited  above,  below, 
and  to  the  right  of  this  point.  On  closer  palpation,  or  by  bimanual 
palpation  with  one  finger  in  the  rectum  and  the  flat  finger  tips  over 
the  region,  one  can  usually  make  out  the  cecum  as  a  sausage-shaped 
mass,  with  one  terminus  at  Poupart's  ligament  and  the  other  fading 
away  toward  the  liver.  It  presents  no  fixed  resistance  to  the  fingers,  as 
it  would  were  it  made  up  of  cecum  filled  with  scybala.  Much  more 
does  it  feel  like  a  bag  filled  with  gas  and  fluid  in  a  state  of  tension,  for 
sometimes  the  rigidity  relaxes  and  the  apparent  tumor  disappears,  nor 
is  it  difficult  to  obtain  gurgling  sounds  by  stripping  the  tumor  in  the 
direction  of  the  ascending  colon.  Evidently  all  the  phenomena,  pain, 
and  the  sense  of  a  tumor  are  due  to  a  paroxysmal  rigidity  of  this 
section  of  the  large  intestine.  Practically  all  patients  suffering  from 
typhlitis  complain  of  constipation,  either  just  before  an  attack  or  con- 
stantly, as  manifested  by  scanty,  infrequent,  or  hardened  stools.  An 
attack  may  also  be  followed  by  a  spontaneous  diarrhea,  during  which, 
at  first,  the  stools  are  noted  for  their  putrid  odor,  and  at  last  for  the 
abundance  of  mucus  which  they  contain.  One  can  interpret  this  se- 
quence in  no  other  way  than  that  a  localized  cecal  inflammation  ex- 
tended to  the  colon  and  the  local  fecal  accumulation  was  relieved.  A. 
Schmidt  is  not  ready  to  hold  constipation  responsible  for  these  attacks 
of  typhlitis,  and,  when  such  is  apparent,  would  make  a  spasm  of  the 


446  DISEASES  OP  THE  DIGESTIVE  TRACT 

colon  above  the  cecum  the  guilty  feature,  A  slight  rise  of  tempera- 
ture (99.5-101)  may  be  present,  but  it  is  of  an  ephemeral  nature  and 
disappears  within  the  first  forty-eight  hours,  while,  on  the  other  hand, 
many  cases  occur  without  any  rise  in  temperature  whatever.  A  corre- 
sponding rise  in  pulse  may  be  observed  or  it  may  be  absent,  while 
the  general  view  seems  to  be  that  there  is  no  increase  in  the  leucocytes, 
or,  at  most,  they  never  rise  above  15,000. 

Diagnosis. — The  diagnosis,  in  spite  of  the  differences  in  uncompli- 
cated cases  between  typhlitis  and  appendicitis,  is  often  very  difficult, 
because  perityphlitis  and  paratyphlitis  frequently  become  associated 
and  then  the  most  skillful  diagnostician  cannot  differentiate  above  a 
probability.  When,  however,  we  find  the  nonrigid  pear  like  or  sau- 
sage-like mass  in  the  iliac  region,  minor  temperature  changes,  absence 
of  increase  in  leucocytes,  and  freedom  from  muscular  spasm,  we  can 
usually  decide  in  favor  of  typhlitis.  To  differentiate  from  typhoid, 
too,  may  require  from  twenty-four  to  forty-eight  hours,  but  the  per- 
sistence of  temperature  in  the  latter,  the  prominent  headache  and  nose 
bleed,  enlarged  spleen,  apathy,  and  later  the  rose  spots,  usually  clear 
up  the  confusion. 

Treatment. — The  treatment  must  vars'  according  to  whether  we  are 
dealing  with  an  acute  or  a  chronic  affair.  If  the  former,  and  we  are 
assured  that  no  localized  peritonitis  is  present,  which  we  can  exclude 
by  absence  of  a  marked  increase  in  temperature,  wiry  pulse,  and  short, 
panting  breathing,  a  tablespoonful  of  castor  oil,  repeated  two  or  three 
times  daily  at  three-hour  intervals  until  free  movements  are  obtained, 
cannot  be  surpassed  for  producing  immediate  results.  "When  the  oil  is 
not  effective,  it  may  be  necessary  to  employ  calomel  in  small  doses,  fre- 
quently repeated,  or  infusum  sennas  compositum  (several  tablespoon- 
fuls).  In  the  meantime  the  patient  is  to  have  no  food,  and,  if  digital 
examination  shows  a  rectum  packed  with  feces,  enemata  of  water,  soap, 
and  glycerin  are  to  be  employed.  It  is  sometimes  astonishing  to  see 
what  a  continuance  of  this  treatment  will  accomplish  in  twenty-four  to 
thirty-six  hours  to  relieve  conditions.  At  one's  visit  the  next  day  the 
tumor  of  the  cecum  has  vanished,  the  pain  disappeared,  and  there  is 
only  a  vague  sense  of  discomfort  on  palpation ;  while  the  patient,  who 
yesterday  was  dreading  an  operation,  is  today  clamoring  for  food. 
If,  as  many  claim,  this  is  but  a  milder  form  of  the  disease  which  kills 
in  thirty -six  hours  and  which  but  few  surgeons  will  consent  to  oper- 
ate after  twenty-four  hours,  then  it  is  most  pleasantly  disguised. 
When  the  pains  continue  after  free  evacuation  of  the  bowels,  10  drops 
of  laudanum  may  be  given  occasionally,  or  a  suppository  of  extractum 


INFLAMMATORY    DISEASES   OF    THE   INTESTINE  447 

opii  and  extractum  belladonnae  aa  0.02  gram  (34  grain).  On  the  other 
hand,  if  the  patient  looks  frail,  there  is  considerable  rise  in  tempera- 
ture, the  pulse  is  hurried,  a  digital  examination  shows  no  accumula- 
tion in  the  rectum,  and  there  is  a  suspicion  of  spasm  of  the  rectus, 
soothing  treatment  should  precede  the  evacuant.  Opium  and  bella- 
donna, or  a  small  hypodermic  injection  of  morphia,  should  be  em- 
ployed, the  patient  must  remain  in  bed,  and  hot  applications  be  applied 
to  the  affected  region.  Then  we  calmly  wait  until  the  active  symptoms 
of  pain  and  rise  of  temperature  have  subsided,  when  the  intestine 
is  to  be  cleared  out  by  castor  oil  or  compound  licorice  powder,  either 
alone  or  aided  by  enemata.  The  diet  during  the  attack  is  best  limited 
to  demulcent  soups — bouillon  with  egg  and  gelatine;  milk  in  many 
cases  is  badly  borne.  T^Then  the  attack  is  over,  the  patient  should  not 
regard  himself  as  cured,  as  he  often  does,  for  there  is  a  latent  irrita- 
tion of  the  cecum  which  may  flame  up  at  any  moment  into  another 
acute  attack.  During  this  quiescent  period,  treatment  should  be  de- 
voted to  warding  off  subsequent  attacks.  If,  as  the  patient  always 
claims,  a  period  of  constipation  ushers  in  such  exacerbations,  then  we 
must  fight  this  condition  with  our  anticonstipation  diet,  given  on  page 
416.  As  such  constipation  is  associated  with  much  spasm  of  the  colon, 
a  fact  of  which  we  can  easily  convince  ourselves,  more  is  demanded  of 
the  physician  than  that  he  shall  simply  say  to  the  patient,  "Eat 
graham  bread  and  greens, ' '  for  these  articles,  containing  much  residue 
in  the  shape  of  cellulose,  do  not  act  as  well  as  the  fruit  juices,  sugar  of 
milk,  and  salted  articles  of  food,  like  cornbeef  and  salt  fish  made  up 
into  hash,  or  the  latter  into  fish  balls.  Raw  vegetables,  radishes,  celery, 
cold  slaw,  and  cucumbers  or  pickles  are  particularly  harmful.  AVhere 
the  stomach  shows  a  faulty  digestion,  especially  where  its  secretion  is 
diminished,  it  may  be  necessary  to  still  further  restrict  the  choice  of 
food  and  employ  hydrochloric  acid  or  pankreon.  Use  laxatives  with 
the  greatest  care  in  this  condition,  and  then  only  the  mildest,  like  puri- 
fied petroleum,  phenolphthalein,  cascara,  agar-agar,  or  rhubarb  root 
may  be  nibbled.  Suppositories  of  belladonna  may  aid  one  greatly  dur- 
ing the  intervals  between  the  acute  attacks  by  allaying  the  spasm  and 
thereby  checking  the  pain,  which  is  often  very  troublesome  at  night. 
This  medicinal-dietetic  treatment  may  be  largely  aided  by  massage, 
which,  even  after  the  first  application,  produces  a  sense  of  relief  from 
tension,  and  by  palpation  it  may  be  found  that  the  region  has  relaxed. 
"When  undue  pain  is  produced,  which  lasts  after  the  immediate  appli- 
cation of  the  hands,  there  is  always  a  suspicion  that  more  than  a  typh- 
litis, a  true  peritoneal  invasion  or  a  chronic  appendicitis,  is  present. 


448  DISEASES   OF   THE   DIGESTIVE   TRACT 

When  one  is  assured  that  massage  is  beneficial,  further  treatment  may 
be  left  to  the  patient,  who  may  apply  vibration  massage  (autovibrator) 
to  this  region. 

The  surgical  treatment  of  this  condition  has  found  many  enthusiastic 
supporters  among  the  internists,  who  have  been  able  to  relieve  many 
cases  in  this  way  when  other  means  of  treatment  failed.  Until  we  are 
assured — as  we  are  not  yet — that  the  inflammatory  condition  comes 
from  the  movable  or  elongated,  firmly  bound  cecum,  there  will  remain 
some  skepticism  in  regard  to  fixation  or  changed  fixation  of  this  part 
of  the  colon.  As  to  the  ileocolic  anastomosis,  as  is  done  for  chronic 
constipation,  our  personal  experience  is  limited,  but  it  is  highly  recom- 
mended by  others.  It  would  seem  as  if,  when  the  danger  of  the  opera- 
tion grows  less  with  better  technic,  it  would  be  admirably  adapted  for 
this  disease  when  chronic  and  incurable  by  medical  means.  AVhat 
every  medical  man  must  object  to  vigorously,  is  this  indiscriminate  re- 
moval of  the  appendix  for  typhlitis,  which  does  not  do  an  atom  of 
good,  and  the  patient  is  returned  to  the  doctor  still  complaining  of  the 
pain  in  his  belly.  Either  do  the  ileocolic  anastomsis  for  this  con- 
dition, colleagues,  or  let  the  victim  alone.  Only  recently  a  surgeon  re- 
ported ninety-eight  consecutive  appendices  removed  for  chronic  ap- 
pendicitis, in  which  one  can  read  typhlitis  in  many  of  the  cases,  and 
rest  assured  that  a  large  percentage  will  continue  to  have  their  belly- 
aches. 

APPENDICITIS. 

Appendicitis  (simple  and  perforative)  suddenly  sprang  into  promi- 
nence when  we  of  the  older  rank  were  comfortably  diagnosing  all  acute 
inflammatory  disturbances  in  the  right  iliac  fossa  as  typhlitis  and  peri- 
typhlitis, according  to  the  severity  of  the  symptoms,  and  calmly  laying 
on  poultices  and  awaiting,  with  bated  breath,  the  ominous  wiry  pulse 
and  general  abdominal  tenderness,  which  spelled  peritonitis  for  a  diag- 
nosis, and  death  to  the  patient  in  most  instances.  This  accusation  and 
conviction  of  the  appendix  as  the  origin  of  much  of  this  trouble  was, 
of  course,  due  to  the  late  Reginald  Fitz,  whose  importance  in  the 
medical  world,  though  our  instructor,  was  not  recognized  by  us  until 
we  heard  his  praises  sounded  in  foreign  hospitals.  At  first  the  sur- 
geon handled  an  inflamed  appendix  very  gingerly,  being  content  to  as- 
pirate after  a  walled-oif  abscess  could  be  demonstrated.  Then  came  a 
series  of  articles  from  the  prominent  surgeons  on  "AVhen  to  operate 
in  Appendicitis,"  to  which  the  apparent  answer  was,  at  all  times, 
under  all  conditions,  as  long  as  breath  was  still  in  the  patient.     Now 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  449 

we  have  reached  an  age  of  reason  when  we  recognize  that  there  are 
some  simple  eases  which  should  never  be  operated,  and  others  are  so 
serious  that  the  patient's  chances  are  better  without  the  use  of  the 
knife.  In  the  meantime  there  are  many  cases  which  are  included  in 
this  middle  ground  and  which  the  internist  as  well  as  the  surgeon 
must  recognize  promptly.  The  simple  catarrhal  appendicitis,  where 
the  walls  are  not  involved  and  there  is  no  perforation,  will  remain  the 
function  of  the  doctor  to  treat,  while  perforation,  gangrene,  and  abscess 
formation  place  the  patient  promptly  in  the  hands  of  the  surgeon,  but 
the  physician  must  recognize  those  cases  liable  to  go  wrong,  for  from 
the  simplest  catarrhal  appendicitis  there  may  arise  an  extension  into 
the  walls  of  the  organ,  involvement  of  the  peritoneum,  perforation,  and 
general  peritonitis. 

The  causation  of  appendicitis  remains  almost  as  obscure  as  when 
it  was  discovered  nearly  thirty  years  ago.  It  is  much  more  frequent 
among  cultivated  people  than  among  the  natives  of  the  wilder  regions 
of  the  earth,  and  much  more  common  among  the  people  of  the  United 
States,  said  to  be  due  to  the  excessive  use  of  meat  and  habitual  consti- 
pation. Still,  among  the  simple-living  New  England  farmers,  from 
tradition,  many  were  victims  of  ''inflammation  of  the  bowels,"  which 
in  modern  nomenclature  reads  peritonitis  and  probably  appendicitis, 
and  a  practitioner  of  eighty  years  or  more  has  described  to  us  during 
our  school-teaching  days  in  his  village  how,  on  "opening"  the  corpse, 
which  has  been  replaced  in  modern  student  nomenclature  by  ' '  posting, ' ' 
he  found  concrements  sometimes  in  the  appendix,  which  imposed  them- 
selves on  him  as  grape  seeds  or  "burnt" — i.e.,  hard-beans,  but  which 
were  probably  small  fecal  concretions.  Another  cause  to  which  is 
ascribed  appendicitis  is  the  colon  cat-arrh,  and  particularly  that  con- 
fined to  the  cecum,  as  well  as  membranous  colitis,  but  one  should  not 
associate  these  two  conditions  too  closely,  for  typhoid,  in  which  the 
cecum  rarely  escapes  wholly,  is  never  accompanied  by  appendicitis. 
An  exclusive  brand  of  bacteria,  metastatic  involvement  from  inflamed 
tonsils,  emboli  from  septic  processes  elsewhere,  and  trauma,  have  all 
been  suggested  as  causative  agencies,  but,  apart  from  the  prevalence  of 
appendicitis  during  influenza,  which  may  have  something  in  it,  all  the 
others  fail  before  the  investigation  of  a  large  series  of  cases.  The  best 
explanation  is  that  the  appendix,  on  account  of  its  lumen,  is  always 
filled  with  bacteria  from  the  colon,  which,  as  long  as  they  pass  back  and 
forth  through  a  patent  outlet,  do  no  harm.  When,  however,  from  the 
extension  of  an  inflammatory  process  in  the  cecum  or  an  enterolith,  a 
closure  of  the  orifice  occurs,  the  same  condition  is  present  as  in  tempo- 


450  DISEASES   OP   THE   DIGESTIVE   TRACT 

rary  closure  of  the  eustachian  tube,  and  inflammation  arises  from  the 
bacteria  as  it  does  in  the  middle  ear. 

Symptoms. — The  symptoms,  of  course,  vary  in  accordance  with  the 
severity  of  the  attack,  but  in  its  milder  form  agree  most  closely  ^^dth 
those  given  for  typhlitis,  apart  from  the  peculiar  palpatory  findings  in 
the  former.  This  simple  catarrhal  appendicitis  may,  in  fact,  run  its 
course  without  symptoms,  as  is  shown  by  the  fact  that  the  appendix  is 
already  ruptured  when  our  attention  is  first  called  to  it.  Still,  these 
are  exceptional  cases,  and,  on  the  whole,  the  patient  describes  a  sudden 
attack  of  rather  severe  pain  in  the  right  lower  half  of  the  abdomen, 
accompanied  perhaps  by  an  attack  of  vomiting  and  a  feeling  of  malaise, 
which  compels  him  to  give  up  his  occupation  and  lie  down.  When 
the  physician  reaches  the  patient,  he  can  indistinctly  detect  a  vague  re- 
sistance of  the  abdominal  muscles  in  the  region  of  McBurney's  point. 
By  careful  palpation,  one  can  discover  neither  resistance  nor  a  rigid 
section  of  the  intestine,  but  tenderness  will  always  be  elicited.  The 
patient  meanwhile  has  somewhat  recovered  and  does  not  seem  par- 
ticularly sick,  his  temperature  is  usually  normal  and  never  exceeds 
100.5°,  and  the  pulse  is  rarely  over  100.  The  bowels  are  confined,  but 
may  spontaneously  begin  their .  functions  after  the  first  day  or  two, 
or  loose  movements  may  follow.  This  condition  usually  lasts  a  couple 
of  days,  but  on  the  third  the  appetite  has  returned  and  the  patient  feels 
perfectly  well.  This  form  of  appendicitis  is  probably  more  common 
than  any  other,  is  usually  described  by  the  physician  as  a  ''touch"  of 
appendicitis,  and  does  not  require  a  surgeon  unless  the  patient's  con- 
dition grows  much  worse  during  the  first  thirty-six  hours.  This  form 
vastly  outnumbers  the  perforative  variety,  is  found  largely  in  our 
out-patient  clinics,  usually  after  the  worst  is  over  and  the  rigidity  of 
the  abdominal  muscles  has  largely  disappeared,  and,  from  the  numbers 
appearing,  certainly  must  be  a  fairly  common  disease.  The  onset  of 
the  attack  is  not  always  so  brusque  as  represented.  Very  often  a 
period  of  loss  of  appetite,  confined  bowels,  flatulence,  eructations,  and 
rumbling  in  the  abdomen  precedes,  and  to  the  self-prescribed  doses 
of  calomel,  rhubarb,  etc.,  during  this  period,  it  has  seemed  to  us,  the 
attack  might  be  due.  Furthermore,  the  onset  may  be  ushered  in  by  a 
more  or  less  prolonged  attack  of  dull  pain  in  the  right  lower  half  of 
the  abdomen,  with  an  occasional  exacerbation,  and  no  other  symptom. 
This  has  been  called  by  some  "appendicular  colic,"  and  regarded  as 
purely  functional,  but  may  be  an  early  stage  of  the  inflammatory 
process.  The  pain,  perhaps  the  most  characteristic  symptom,  is  at  first 
more  or  less  diffuse,  and  may  be  felt  almost  anywhere  in  the  lower 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  451 

abdomen,  but,  under  palpation,  tenderness  is  confined  pretty  closely  to 
the  point  where  the  spinous-navel  line  cuts  the  outer  right  rectus.  By 
putting  the  patient  in  bed,  too,  the  pain  soon  localizes.  This  limita- 
tion of  the  pain  does  not  convey  to  one  any  idea  where  the  appendix 
may  be  found,  for  in  two  cases  under  our  observation — one  in  which  the 
appendix  popped  through  the  wound  as  soon  as  made  and  the  other 
where  the  appendix  was  resting  on  the  vertebrge — the  pain  and  tender- 
ness remained  the  same.  Palpation  in  appendicitis  is  painful,  and  is 
avoided  as  much  as  possible  by  the  patient,  while  in  typhlitis  it  is  not. 
It  is  felt  most  severely  when  the  hand  is  withdrawn  (pressure  relaxed) 
than  when  applied  to  the  abdomen.  Pressure,  too,  applied  elsewhere 
upon  the  walls  is  felt  at  McBurney's  point;  this  is  not  only  true  of 
appendicitis,  but  also  of  other  affections  in  the  ileocecal  region.  As  a 
rule,  this  region  is  neither  distended  nor  retracted,  nor  is  the  muscular 
spasm  so  intense  that  one  cannot  palpate  the  points  underneath. 
When  one  has  overcome  the  muscular  resistance,  one  feels  not  only  no 
mass,  but  usually  no  intestinal  parts.  Very  rarely  the  cecum  and 
ascending  colon  can  be  felt  as  a  contracted  cord,  but  ordinarily  the 
tenderness  prevents  any  actual  mapping  out  of  the  parts.  Whether 
one  can  feel  the  inflamed  appendix,  still  remains  very  much  in  doubt, 
particularly  during  an  acute  attack.  When  anything  definite  can  be 
palpated  in  this  region,  it  is  much  more  likely  to  be  the  swollen  terminal 
section  of  the  ileum  where  it  enters  the  cecum,  or  possibly  the  latter 
in  a  state  of  spasmodic  contraction.  Our  owti  experience  in  palpating 
an  appendix  successfully  is  confined  wholly  to  the  chronic  cases  or  in- 
termissions between  acute  attacks,  when  at  various  times  it  has  seemed 
that  the  appendix  was  perceptible.  In  an  acute  attack,  however,  it 
has  never  been  our  good  fortune  to  feel  the  organ,  and  we  believe 
that  force  necessary  to  overcome  the  muscular  spasm  and  penetrate  the 
edematous  tissues  is  entirely  unjustifiable.  The  entire  gastrointestinal 
tract  is  sometimes  affected  by  reflex  influences,  and  an  attack  of  pain 
is  ushered  in  by  vomiting,  though  rarely  not  more  than  twice.  This 
also  offers  a  differential  diagnostic  point  to  typhlitis,  where  emesis  is 
rare.  From  the  same  reflex  agency  we  have  a  temporary  constipation, 
which  usually  takes  care  of  itself  after  the  irritation  is  over.  It  is  a 
great  mistake  to  begin  at  once  to  fight  this  confinement  of  the  bowels 
with  laxatives,  as  some  do.  The  rarely  accompanying  diarrhea  is 
difficult  to  explain,  and,  fortunately,  is  rare,  for  it  has  led  many  an 
incautious  practitioner  to  treat  an  appendicitis  like  a  gastroenteritis. 
This  may  also  be  nervous,  but  the  better  explanation  is  that  an  inflam- 
matory disturbance  of  the  general  intestinal  tract  takes  place.     The 


452  DISEASES   OF   THE   DIGESTIVE   TRACT 

appearance  of  the  patient  is  not  much  disturbed  in  the  simple  form. 
In  an  analysis  of  120  cases,  Sonnenburg-Kothe  found  the  temperature 
average  99.5°,  the  pulse  92,  and  the  leucocytes  15,000,  while  in  101 
cases  of  the  perforative  form  the  corresponding  figures  were  101  de- 
grees, 112,  and  22,500.  From  such  figures,  at  least,  we  may  learn  that 
in  the  simple  form  the  departure  from  the  normal  is  not  marked.  The 
chief  point,  however,  is  the  rapid  subsidence  of  the  symptoms  after 
forty-eight  hours;  if  the  temperature  persists  or  recurs,  we  are  then 
to  look  on  the  case  with  suspicion.  The  hyperleucocytosis  is  also  a  very 
significant  guide  in  differentiating  the  simple  form  from  the  perfora- 
tive or  destructive  variety.  In  the  former  the  number  never  exceeds 
15,000,  but,  when  the  purulent  secretion  stagnates  or  infiltration  of  the 
submucosa  takes  place,  then  up  goes  the  leucocyte  count.  Thus  an  in- 
crease of  the  leucocytes  above  15,000  means  a  destructive  form  of  the 
disease,  with  probable  involvement  of  the  peritoneum.  Unfortunately, 
the  reverse  of  this  is  not  true ;  we  may  have  a  destructive  septic  process 
of  the  appendix  and  fairly  extensive  peritonitis  with  a  diminution  of 
white  corpuscles  rather  than  an  increase.  The  change  from  the  simple 
catarrhal  to  the  destructive  perforative  form  must  always  be  watched 
for  with  great  care,  for,  as  the  surgeons  declare,  the  mildest  form  may 
finally  emerge  into  the  most  virulent.  It  will  be  noted  that  the  patient 
who  for  two  or  three  days  has  been  ** comfortably  sick,"  as  the  ex- 
pression is  used,  but  still  retained  in  bed  for  precaution,  suddenly  has 
a  recurrence  of  pain,  which  is  even  more  severe  than  at  first,  and  a 
sharp  rise  of  temperature,  with  a  possible  chill,  and  evidences  of  mild 
collapse.  This  is  the  story,  provided  the  patient  w^as  seen  from  the 
beginning.  Much  oftener,  however,  the  early  symptoms  were  neg- 
lected by  him  and  we  see  the  victim  first  with  the  second  stage  of 
appendicitis  in  full  swdng;  the  right  leg  is  drawn  up  to  relieve  the 
tension  of  the  muscles,  the  respiration  is  shallow  because  the  chest  is 
held  on  account  of  pain;  there  is  marked  rigidity  over  the  ileocecal 
region,  and  more  or  less  prominence  wdth  marked  resistance,  and  light 
percussion  w411  not  fail  to  show  dullness ;  the  temperature  is  always  be- 
yond 100.5°  and  the  pulse  above  100;  the  bowels  remain  obstinately 
confined,  and  often  urination  is  associated  wdth  pain. 

CHRONIC  APPENDICITIS. 

Chronic  appendicitis  is  a  disease  difficult  to  describe  because  of  the 
recurrences  of  acute  attacks  and  the  marked  reparative  changes  about 
the  organ,  produced  after  the  first  attack.     That  any  individual  who 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  453 

has  suffered  one  attack  is  liable  within  a  year  to  have  another  is  recog- 
nized by  all;  in  fact,  statistics  show  that  this  liability  to  recurrence 
can  be  expressed  in  figures,  which  are  variously  given  as  from  20-35 
per  cent  in  round  numbers.  When  the  patient  says  that  after  one 
mild  attack  of  pain  in  this  region,  which  perhaps  did  not  take  him  to  a 
physician,  he  had  absolutely  no  discomfort  until  his  present  attack,  we 
cannot  speak  of  a  chronic  form,  but  the  recurrence  of  an  acute.  When, 
however,  the  attacks  come  close  together  and  the  patient  is  never  free 
from  discomfort  in  that  region  during  the  interval,  then  we  have  a 
true  chronic  form.  When,  finally,  the  surgeon  removes  the  appendix 
of  an  individual  with  this  history,  there  may  be  evidences  of  former 
inflammatory  attacks  and  local  peritonitis  in  the  form  of  bands  or  ad- 
hesions, which  bind  the  appendix  firmly  to  the  colon,  to  an  ovary,  or 
to  the  parietal  peritoneum;  kinks  are  common,  and  perhaps  the  ap- 
pendix may  contain  encapsulated  serum  or  pus,  and  at  times  it  must 
be  said,  in  spite  of  symptoms,  that  the  onlooker  fails  to  find  any  change, 
though  the  surgeon  usually  discovers  some  pathological  transformation, 
real  or  imaginary,  for  its  removal ;  in  fact,  a  surgeon 's  antipathy  for  an 
appendix  can  be  likened  only  to  that  of  a  bull  for  a  red  article.  Then, 
in  addition  to  these  repeated  frank  attacks  of  mild  appendicitis,  we 
have  the  form  in  which  no  history  of  an  acute  attack  can  be  obtained, 
termed  by  various  authors  as  "sneaking,"  "masked,"  and  "con- 
cealed," It  can  at  once  be  seen  that  the  pathological  conditions  vary 
so  greatly  that  it  is  beyond  the  power  of  man  to  diagnose  the  state  of 
the  appendix  from  the  symptoms  and  palpatory  findings,  so  that  we 
are  forced  to  refer  to  the  disease  simply  as  "chronic  appendicitis," 
with  and  without  exacerbations. 

Sjnnptoms. — The  symptoms  vary  in  accordance  with  the  form  pre- 
dominant, but,  apart  from  acute  accessions,  consist  of  uncomfortable 
sensations  in  the  right  lower  half  of  the  abdomen,  without  actual 
colicky  attacks,  but  invariable  sensitiveness  to  pressure  over  McBur- 
ney's  point.  Gastroenteric  symptoms  of  various  kinds  may  also  arise, 
eructations,  pressure  after  eating,  and  occasional  attacks  of  diarrhea, 
with  discharge  of  mucus,  from  reflex  irritation  of  the  appendix.  The 
special  pain  may  be  sharply  localized  in  the  region  of  McBurney's 
point,  or  may  be  generally  distributed  over  the  right  half  of  the  ab- 
domen, or  even  extend  to  the  left.  Light  pressure,  massage,  etc.,  some- 
times relieves  the  dull  pain,  while  occasionally  individuals  become  so 
accustomed  to  it  that  they  note  only  exacerbations.  As  the  muscular 
spasm  is  practically  always  wanting,  it  is  not  usually  difficult  to  map 
out  the  cecum,  and  sometimes  feel  the  appendix  as  a  finger-like,  sensi- 


454  DISEASES   OF   THE   DIGESTIVE   TRACT 

tive  body,  lying  on  the  former,  Oftener,  however,  the  thickened 
appendix  lies  back  or  to  the  side  of  the  cecum  and  escapes  palpation. 
In  this  connection  two  aids  are  offered  us — either  the  bimanual  palpa- 
tion, with  one  finger  in  the  rectum,  or  Hausmann's  trick  of  raising 
the  extended  leg  on  the  trunk,  so  as  to  put  the  psoas  on  the  stretch, 
which  offers  a  good  table  against  which  one  attempts  to  feel  the  ap- 
pendix. 

The  general  health  of  the  patient  suffers  according  to  his  suscepti- 
bility, and  very  often  he  or  she  becomes  very  hypochondriacal. 
Women  suffer,  too,  from  menstrual  irregularities,  perhaps  from  the  ad- 
hesion of  the  appendix  to  the  right  ovary,  and  the  pain  is  always  ac- 
centuated just  before  menstruation. 

Diagnosis. — The  diagnosis  of  the  acute  form  is  not  difficult,  though 
sometimes  gallstone  or  renal  colic,  tabetic  enteralgias,  right-sided 
pleuritis,  right-sided  salpingitis,  invagination,  or  incarcerated  hernia 
pose  as  appendicitis.  But  much  more  careful  must  we  be  to  avoid  con- 
fusing a  myalgia  of  the  right  rectus,  which,  as  is  well  known,  may  pro- 
duce a  spasm  with  an  inflamed  appendix.  Such  a  condition  may  be 
brought  on  by  a  cold,  with  a  slight  cough,  by  which  the  muscle  is  thrown 
into  unusual  exertion.  Here,  though,  superficial  pressure  produces 
much  more  distress  than  deep,  and,  again,  the  bimanual  examination 
with  the  finger  in  the  rectum  can  be  made  without  a  complaint  from 
the  patient  of  tenderness.  The  diagnosis  of  chronic  appendicitis  where 
no  acute  attacks  have  ever  occurred  may  be  completely  impossible  when 
the  general  symptoms  of  indigestion  prevail  over  the  local  ones  and  the 
thickened  appendix  cannot  be  felt.  Here,  however,  is  where  one  may 
meet  tuberculosis,  cancer,  and  chronic  invagination  of  the  ileum  into 
the  cecum,  which,  of  course,  must  be  carefully  differentiated. 

In  no  disease  is  the  prognosis  so  uncertain  as  in  this.  In  all  proba- 
bility all  the  simple  catarrhal  forms  will  recover  as  long  as  they  remain 
catarrhal,  but  here  is  where  our  foresight  fails  us,  and  we  can  say 
only  from  day  to  day  that  the  dreaded  extension  to  the  peritoneum 
has  not  taken  place.  For  these  reasons  most  internists  consult  a 
surgeon,  and  then  perhaps  smile  when  he  removes  an  apparently 
healthy  appendix,  but  our  anxiety  is  allayed  because  no  further  danger 
can  occur. 

Treatment. — The  treatment  comprises  largely  the  solution  of  the 
problem  whether  the  patient  shall  be  operated  or  not.  This  prob- 
lem, in  turn,  is  based  on  the  character  of  the  inflammatory  process 
— simple  catarrhal  or  penetrative,  destructive,  or  any  other  term  w^hich 
one  may  choose  to  employ.     The  former  can  be  well  left  to  the  usual 


INFLAMMATORY    DISEASES   OF    THE   INTESTINE  455 

treatment  of  local  inflammation,  the  latter  demands  the  aid  of  the  sur- 
geon, and  the  sooner  the  better.  Then,  owing  to  the  unfortunate  tend- 
ency of  the  simple  form  to  become  destructive,  it  may  be  necessary  at 
any  moment  to  interrupt  the  medicinal  treatment  and  interpose  the 
surgical.  The  difficult  point,  and  the  point  on  which  physicians  and 
surgeons  do  not  always  agree,  is,  when  has  a  simple  appendicitis  be- 
come a  destructive  one.  This  period  the  advocates  of  the  early  opera- 
tion would  place  at  twenty-four  hours  after  the  first  pain  arises,  while 
others  place  it  at  forty-eight  hours  if  alleviation  of  the  symptoms  has 
not  occurred.  In  our  estimation  it  is  entirely  useless  to  talk  about  a 
restoration  to  health  in  twenty-four  hours.  True,  in  forty-eight  hours 
the  spontaneous  pain,  rise  in  temperature,  and  increased  pulse  may 
subside,  but  the  tenderness  on  palpation  remains  for  some  time  longer. 
The  more  we  study  appendicitis,  however,  the  more  we  are  dissatis- 
fied with  fixed  time  limits.  One  person  will  show  more  disturbance  in 
eighteen  hours  than  another  in  forty-eight  hours,  and,  still,  at  opera- 
tion the  lesion  may  be  practically  the  same.  Nothing  impresses  itself 
on  one  more  than  the  individuality  of  every  ease,  and  the  decision  as  to 
simple  or  destructive  form  must  not  be  made  according  to  the  clock, 
but  according  to  symptoms.  Whenever  a  rise  in  temperature,  an  in- 
crease in  pulse,  a  chill,  or  greater  rigidity  of  the  muscular  spasm  of 
the  abdomen  occurs,  or  these  are  continuous  w^hen  found  at  the  first  ex- 
amination of  the  patient,  then  the  surgeon  is  to  be  called  at  once  and 
the  physician  is  to  be  guided  wholly  by  his  advice.  When,  on  the  con- 
trary, slight  rise  of  temperature,  pulse  under  100,  and  moderate  spasm 
continue  longer  than  forty-eight  hours,  with  no  accession,  we  may  pro- 
ceed confidently  to  treat  the  patient  medicinally,  with  no  great  fear  of 
the  outcome.  If  in  rural  districts  a  surgeon  cannot  be  readily  reached 
and  a  cottage  hospital  is  in  the  vicinity,  there  can  be  no  objection  to 
the  removal  of  the  patient  to  it,  so  that  both  physician  and  surgeon 
may  watch  the  progress  and  a  prompt  operation  performed  in  case  of 
necessity,  but,  on  account  of  the  surgeon's  animosity  tow^ard  the  ap- 
pendix, as  mentioned,  he  is  not  always  the  safest  adviser  as  to  the 
necessity  of  operation. 

Let  us  take  it  for  granted  that  no  operation  is  needed.  Are  w^e  to 
treat  our  patient  with  laxatives  or  opium,  two  w^ell-recognized  methods 
of  management  ?  It  may  be  said,  as  Clarke  first  remarked,  that  opium 
' '  puts  the  intestine  in  splints, ' '  but  at  the  same  time  it  dulls  the  pain, 
our  most  valuable  guide  in  determining  the  severity  of  the  process. 
Again,  for  the  milder  cases  castor  oil  has  proven  almost  miraculous  in 
its  action,  removing  all  symptoms  in  the  simple  catarrhal  form  in 


456  DISEASES   OF   THE   DIGESTIVE   TRACT 

twenty-four  hours.  It  has,  further,  proved  to  us  how  much  more 
common  the  simple  form  is  than  we  supposed,  yet  there  can  be  no  ques- 
tion that,  if  the  appendix  shows  any  tendency  to  assume  the  destructive 
form,  any  laxative  certainly  does  tear  up  new-formed  protective  ad- 
hesions and  has  undoubtedly  caused  more  general  peritonitis  than  any 
other  agency.  At  least,  in  our  experience  the  worst  forms  seen  were 
those  Avhere  the  patient,  on  his  own  responsibility,  had  taken  large 
doses  of  calomel  or  compound  cathartic  pills.  An  interesting  volume 
has  been  published  on  "what  to  do  before  the  doctor  arrives,"  but 
here  is  an  instance  where  what  not  to  do  would  be  more  valuable. 
When,  how^ever,  the  pain  is  moderate,  the  general  condition  not  much 
impaired,  and  the  patient  declares  that  only  inadequate  or  irregular 
stools  have  occurred,  we  may  give  1-2  tablespoonfuls  of  castor  oil,  as 
in  typhlitis,  or  our  calomel  in  divided  doses.  When,  on  the  contrary, 
the  pulse  is  hurried,  the  pain  more  intense,  and  spasm  marked,  while 
there  is  no  history  of  preceding  constipation,  10  drops  of  laudanum 
twice  a  day  will  dull  the  pain  without  eradicating  it,  and  allow  the 
physician  to  make  some  estimate  of  the  severity  of  the  disease.  A 
suppository  of  extractum  opii  and  extraetum  belladonna  aa  0.02  (^ 
grain)  once  a  day  will  usually  serve  the  same  purpose.  Hypodermics 
of  morphine  are  absolutely  contraindicated  unless  the  suffering  of  the 
patient  is  excessive  and  a  speedy  operation  has  been  decided  on.  A 
repetition  of  the  dose  of  opiate  should  always  be  delayed  until  the 
patient  clamors  loudly  from  pain,  or  palpation  of  this  region  arouses 
distinct  suffering;  else  the  physician  will  live  in  a  dream  of  his  pa- 
tient's recovery  until  collapse  shows  that  a  rupture  has  taken  place. 
An  application  of  an  ice  bag  to  the  painful  region  is  a  worldwide  cus- 
tom, but  its  weight  is  often  objectionable,  and  its  power  to  subjugate 
inflammation  far  below  the  surface  is  doubtful.  A  hot  water  bag 
placed  against  this  region,  with  the  patient  on  the  side  in  bed,  so 
that  the  weight  of  the  bag  is  not  sustained  by  the  abdominal  wall — or, 
better,  when  it  can  be  procured,  the  electric  pad — is  vastly  more  grate- 
ful to  the  patient,  and  particularly  with  the  opium  treatment,  where 
we  are  trying  to  check  peristalsis  of  the  intestine  and  alleviate  pain, 
much  better  adapted.  The  diet  should  be  of  the  blandest  character 
— oatmeal,  barley,  or  tapioca  gruel,  or,  better  still,  if  the  patient  is 
well  nourished,  complete  abstinence  from  food  for  a  couple  of  days. 
Even  when  the  symptoms  subside  after  forty-eight  hours,  it  is  not 
wise  to  allow  the  patient  to  immediately  resume  his  former  life,  but  he 
should  be  kept  quiet  on  a  couch  for  a  week  at  least. 

The  chronic  or  recurrent  appendicitis  has  nothing  before  it  but  an 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  457 

operation — naturally  during  an  interval.  The  majority  of  these  suf- 
ferers have  three  to  five  years  of  discomfort  behind  them,  while  the 
best  skill  of  many  physicians  has  been  exercised  on  them.  They  should 
always  be  warned,  however,  that  complete  recovery  will  not  immedi- 
ately follow  an  operation,  for  adhesions  are  usually  numerous  and  some 
will  reform.  In  case  the  patient  declines  operation,  much  can  be 
done  by  massage,  provided  no  acute  attack  has  occurred  within  six 
months.  The  exudate,  which  can  sometimes  be  felt,  will  be  found  to 
grow'  smaller  as  massage  continues.  Every  effort  should  be  made, 
too,  with  the  anticonstipation  diet — sugar  of  milk,  fruit  juices,  honey, 
agar-agar,  and  petroleum — to  prevent  the  accumulation  of  feces  in  the 
cecum,  thereby  improving  the  circulation  in  those  parts, 

COLITIS. 

Colitis  is  much  more  common  as  an  entity  than  an  inflammation  of 
the  small  intestine.  One  reason  for  this  is  that  the  inflammatory  proc- 
ess, starting  in  the  ileum,  readily  makes  its  way  through  the  ileocecal 
valve  into  the  colon,  but  the  reverse  course,  from  the  large  to  the  small 
intestine,  is  not  so  easily  accomplished  on  account  of  the  peculiar  con- 
figuration of  the  valve,  which  allows  reverse  peristalsis  only  under 
pathological  conditions.  Then,  too,  the  longer  delay  of  the  feces  in 
the  colon  renders  it  more  liable  to  irritation ;  even  the  small  intestine, 
with  its  five  to  six  times  greater  length,  retains  the  food  only  three  to 
four  hours,  while  the  passage  of  the  feces  through  the  colon  requires 
twenty  hours.  It  is  not  true,  however,  that  all  parts  of  the  colon  are 
equally  susceptible  to  these  injurious  influences.  Those  portions  with 
angles  through  which  the  feces  pass  with  difficulty  on  account  of  me- 
chanical hindrance — ^like  the  cecum,  flexures,  sigmoid,  and  rectum — 
are  the  most  liable.  Furthermore,  colitis  shows  a  vastly  greater  tend- 
ency toward  recurrence  and  chronicity,  and  is  much  more  under  the 
influence  of  reflex  (uterus  and  ovaries  in  women,  prostate  and  bladder 
in  men)  and  central  nervous  influence  (vagotonus)  than  the  small  in- 
testine. Another  strong  tendency  of  colitis,  unshared  by  the  small  in- 
testine, is  to  form  adhesions  by  the  extension  of  the  inflammatory 
action  (pericolitis)  to  the  adjoining  structures.  On  account  of  the 
various  manifestations  of  colitis,  it  will  be  necessary  to  discuss  inflam- 
mation of  special  sections,  like  the  sigmoid  and  rectum,  under  sub- 
divisions of  colitis. 

The  causation  of  colitis  may  be  the  same  as  that  of  enterocolitis, 
from  which  the  small  intestine  quickly  recovers,  leaving  the  colon 


458  DISEASES   OF   THE   DIGESTRTi:   TRACT 

chronically  inflamed,  or  the  original  disease  may  have  been  confined  to 
the  colon,  as  in  elimination  of  mercury  in  specific  treatment,  or  en- 
trance of  bacteria  orally  or  through  the  blood,  as  in  dysentery.  The 
delay  of  the  feces  in  the  colon,  encouraged  by  the  various  loops  and 
distortions  of  which  that  part  of  the  colon  is  liable,  also  has  its  in- 
fluence. Furthermore,  the  common  occurrence  of  polypi  in  the  large 
intestine  and  the  less  common  one  of  malignant  disease,  which  always 
manifest  themselves  in  the  early  stage  as  a  colon  catarrh,  will  account 
for  some  instances.  The  colon  also  proves  itself  much  more  sus- 
ceptible to  the  invasion  of  tuberculosis,  its  favorite  site  being  the  anus, 
sigmoid,  and  cecum.  As  stated,  it  does  not  require  a  very  severe  at- 
tack of  colitis  to  lead  to  ulcers,  which  in  turn  attack  the  submucosa,  the 
muscular  structure,  and  the  peritoneal  layer,  though  no  symptoms  per- 
taining to  the  peritoneum  may  be  noted  on  account  of  the  violence  of 
the  catarrhal  symptoms.  The  frequency  with  which  these  adhesions 
are  found  at  any  operation  requiring  the  opening  of  the  abdomen 
shows  how  common  this  sequence  is. 

Symptoms. — The  symptoms  of  the  acute  attack  do  not  differ  to  any 
extent  at  first  from  those  of  an  ileocolitis,  already  described  on  page 
434.  The  stomach  is  much  less  liable  to  be  involved,  and,  if  affected 
(vomiting),  it  is  only  temporary.  The  stool  soon  changes,  however, 
and  consists  of  almost  no  food  material,  but  large  amounts  of  mucus 
and  blood,  or,  rather,  bloody  mucus,  are  passed  after  severe  abdominal 
cramps  and  followed  by  painful  tenesmus.  While  there  is  marked 
disturbance  of  the  general  health  at  first,  even  presence  of  chills,  this 
soon  passes  off;  the  appetite  returns,  and  there  remains  only  this  in- 
cessant desire  for  stool,  which  awakens  the  patient  at  any  hour  of  the 
night  and  must  be  gratified  in  order  to  secure  relief  from  the  distress. 
There  is  also  a  painful  sense  of  cramp  in  the  rectum,  and  vesical  tenes- 
mus, with  frequent  micturition,  may  accompany  it.  The  painful 
cramps  and  tenesmus  gradually  disappear,  but  the  frequency  of  move- 
ments continues,  so  that,  as  some  patients  express  it,  "they  are  never 
sure  of  their  intestine";  the  call  to  stool  may  come  at  any  moment 
and  is  imperative.  Recurrent  attacks  of  the  acute  form  may  occur 
or  the  disease  develop  into  the  chronic  state. 

Physical  examination  verifies  the  inferences  from  symptoms.  The 
temperature  at  first  often  reaches  102  degrees,  the  abdomen  is  some- 
what distended,  but  never  to  such  an  extent  as  to  interfere  with  palpa- 
tion. When  tenderness  is  elicited,  it  is  not  over  the  entire  colon,  but 
at  certain  points,  like  the  cecum,  flexures,  or  the  sigmoid,  though  the 
colon  may  be  found  contracted  in  its  entire  length.     When  the  spasm 


INFLAMMATORY    DISEASES   OF    THE   INTESTINE  459 

of  the  anal  sphincter  can  be  overcome  and  the  rectoscope  introduced, 
the  rectum  will  be  found  intensely  reddened  with  punctate  hemor- 
rhages and  covered  with  blood-stained  mucus.  The  feces  in  acute 
colitis  at  first  contain  food  particles  from  association  of  the  small  in- 
testine, but  in  a  short  time  the  stools,  which  up  to  this  period  have 
been  liquid,  may  assume  a  hardened  consistency,  or,  strange  to  say, 
some  stools  may  be  found  solid  and  others  liquid  on  the  same  day, 
made  up  very  largely  of  bands  and  shreds  of  mucus,  rolled  up  and 
thoroughly  impregnated  wuth  fecal  matter,  in  which  absolutely  none 
of  the  recognized  food  elements — starch,  fat,  and  meat  fibers — can  be 
discovered.  On  the  contrary,  attached  to  the  mucus,  when  freed  from 
fecal  matter  (suspended  in  distilled  water  over  night),  are  found  all 
forms  of  leucocytes,  some  erythrocytes,  multitudinous  epithelial  cells  in 
every  stage  of  granular  transformation,  with  well-preserved  nuclei. 
Again,  shreds  of  mucus  may  be  fished  out  of  the  stool  when  the  lower 
section  of  the  colon  is  involved,  with  no  admixture  of  fecal  matter 
whatever.  Innumerable  bacteria  can  also  be  seen,  and  the  addition  of 
a  drop  of  iodine  solution  brings  out  clearly  many  microorganisms 
containing  granulose.  The  bacterial  examination  in  these  sporadic 
cases  offers  but  little  light  as  to  the  causation,  but  should  be  made 
where  several  cases  occur  in  the  same  vicinity,  to  exclude  the  possi- 
bility of  an  infectious  dysentery  (Shiga,  Flexner,  etc.).  As  the  stools 
grow  less  numerous  and  less  and  less  mucus  appears  in  them,  it  is  still 
found  that  painful  sensations  persist  at  the  hepatic  and  splenic 
flexures,  while  tenderness  to  pressure  can  also  be  elicited.  There  is  no 
question  that  at  these  points,  on  account  of  the  frequent  difficulty  of 
forwarding  the  fecal  contents,  the  inflammation  persists  long  after  the 
colon  is  restored  to  its  normal  state.  This,  perhaps,  is  not  so  vividly 
brought  out  in  the  acute  as  in  the  chronic  form,  where  these  points 
seem  to  be  the  only  parts  of  the  colon  affected.  The  severity  of  the  at- 
tacks varies  so  widely  that  they  seem  to  be  different  forms  of  disease. 
We  may  have  a  few  slimy  discharges  and  the  affection  is  over,  or  there 
may  be  so  many  bloody  mucopurulent  discharges  that  the  patient  is 
completely  prostrated,  and  the  disease  assumes  the  type  of  a  peritonitis. 
The  abdomen  may  be  distended,  hard  as  a  board,  and  extremely  pain- 
ful ;  here  Sonnenburg  would  make  use  of  the  blood  count  for  differenti- 
ation. Colitis  is  never  accompanied  by  more  than  10,000  leucocytes — 
at  most,  15,000 — while,  of  course,  peritonitis  has  no  limit.  There  may 
be  a  small  amount  of  albumin  in  the  urine  and  hyaline  casts.  True 
peritonitis  may  occur  from  colitis,  as  stated,  but  restricted  usually  to 
well-defined  sections  of  the  tract,  the  sigmoid  (perisigmoiditis)  and  the 


460  DISEASES  OF   THE  DIGESTIVE   TRACT 

cecum  (perityphlitis).  Thrombosis  of  either  femoral  vein  (milk  leg) 
may  also  occur  from  the  infection.  When  pericolitic  complications 
manifest  themselves,  the  temperature,  which  perhaps  had  subsided, 
shoots  up  again,  the  pain  increases,  sometimes  a  muscular  spasm  is 
found  over  the  affected  site,  and  palpation  discloses  an  extremely 
tender  spindle-shaped  mass  about  the  colon.  This  may  be  readily  de- 
tected when  it  occurs  at  the  cecum  or  sigmoid,  but  is  vastly  more  diffi- 
cult to  detect  at  the  flexures,  where  the  symptoms  may  be  ascribed  to 
gastric  ulcer,  cholecystitis,  etc.  This  is  particularly  true  of  some  peri- 
colitic processes,  which  begin  de  novo  without  the  preceding  period  of 
frequent  painful  movements.  These  pericolitic  inflammatory  proc- 
esses, too,  are  responsible  for  the  adhesions  found  so  often  between  the 
two  branches  of  the  hepatic  flexure,  and  less  oftener  the  splenic. 

The  differentiation  from  the  enterocolitis  is  made  chiefly  by  the  per- 
sistent absence  of  food  particles  in  the  stool,  and  from  typical  typhlitis 
and  appendicitis  by  the  absence  of  blood-stained,  loose  stools  in  the  lat- 
ter; though,  as  we  have  learned,  appendicitis  may  be  sometimes  accom- 
panied by  frequent  slimy  movements.  One  should  be  cautious  in 
predicting  the  outcome  of  an  acute  colitis.  Old  people  often  succumb 
to  prostration,  and  young  people  can  never  be  promised  a  freedom  from 
chronicity.  Young  men  of  perfect  physique,  even  athletes,  have  come 
to  us  with  a  chronic  colitis  which  was  the  outcome  of  only  one  acute 
attack,  and  treated  according  to  the  most  approved  methods. 

Treatment. — The  treatment,  unless  the  stools  are  free  from  fecal 
matter  when  the  patient  is  first  seen,  should  be  ushered  in  by  a  couple 
of  tablespoonfuls  of  castor  oil,  which  is  superior  to  calomel  on  account 
of  the  possibility  that  the  latter  may  produce  an  ulcer  of  the  colon. 
Then  the  use  of  laxatives  is  to  cease,  and,  to  control  tenesmus,  a  sup- 
pository of  opium  and  belladonna  may  be  employed.  Certain  drugs 
liave  won  some  renown  against  that  form  of  colitis  known  as  dysentery, 
which  may  also  be  used  in  noninfectious  varieties,  but  not  always  with 
the  same  excellent  results.  Ipecac  is  one  of  these,  which,  in  the  form 
of  a  powder,  in  doses  of  0.3  gram  (5  grains)  can  be  given  twice  daily, 
with  an  initial  dose  of  5  drops  of  laudanum  to  check  the  nausea.  This 
remedy  cannot  be  profitably  employed  more  than  two  days  in  suc- 
cession, but  after  a  short  interval  another  two  days'  treatment  can  be 
carried  out.  Enemata  are  indicated  very  early  in  the  course  of  the 
disease,  and  a  vast  number  of  medicaments  have  been  suggested  and 
employed,  some  successfully  and  more  unsuccessfully,  in  combating 
the  disease.  One  must  refrain  from  this  treatment,  however,  as  long 
as  there  is  marked  tenesmus,  since  the  patient  cannot  endure  it,  and 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  461 

the  retention  is  so  short  that  nothing  can  be  gained.  A  teaspoonful  of 
Carlsbad  salts,  dissolved  in  a  quart  of  warm  water,  may  be  the  earliest, 
used  because  the  least  irritating,  and  it  serves  very  well  to  clean  out 
the  mucus  when  the  inflammation  is  low  down  in  the  tract.  Two- 
grams  (30  grains)  of  bismuth  subgallate  added  to  a  cup  of  thin  starch 
or  gum  arable  suspension,  with  10  drops  of  laudanum,  can  be  intro- 
duced slowly  and  often  retained  all  night,  with  decided  benefit  to  the 
colon,  as  evinced  by  lessened  mucus  and  diminution  of  stools.  Gentle 
massage  of  the  abdomen  after  the  enema  causes  it  to  become  more 
widely  distributed  through  this  portion  of  the  intestine. 

The  dietetic  treatment  is  very  simple.  Only  liquid  food,  gelatine, 
cocoa,  and  broth,  as  long  as  examination  of  the  stools  shows  any  par- 
ticipation on  the  part  of  the  duodenum,  should  be  given;  then  soft 
boiled  eggs,  toast  and  butter,  chopped  meat  free  from  fiber,  and  light 
puddings — like  rice,  cottage,  tapioca,  etc. — can  be  employed,  but  a  re- 
turn to  the  customary  mixed  diet  must  be  forbidden  until  the  stools- 
are  formed,  and  particular  precaution  should  be  taken  against  vege- 
tables with  much  cellulose,  like  greens,  lettuce,  turnip,  cauliflower,  and 
cabbage. 

CHRONIC  MUCOUS  AND  MEMBRANOUS  COLITIS. 

Chronic  mucous  and  membranous  colitis  should  really  be  considered 
under  the  acute  form,  but  there  is  so  much  uncertainty  as  to  whether 
many  of  these  cases  ever  had  any  relation  to  a  sudden  onset  and  were 
not,  so  to  speak,  chronic  from  the  beginning,  that  we  hesitate  to  link 
them  up  with  the  former,  though  the  name  implies  their  relation. 
Then,  there  are  still  doubters  of  the  fact  that  they  are  really  inflam- 
matory at  all,  and  would  bring  them  under  the  nervous  disorders, 
much  as  an  attack  of  asthma.  At  least  the  history  of  each  case  shows, 
disturbed  defecation,  now  incomplete,  now  restrained  over  a  day  or 
two,  very  many  nervous  manifestations,  and  the  description  of  occa- 
sional discharges  of  almost  pure — i.e.,  unmixed  with  feces — bands, 
and  shreds  of  mucus,  which  may  be  preceded  by  severe  attacks  of  pain.. 
When,  however,  one  follows  by  examination  of  the  feces  the  course  of  a 
case  of  this  sort,  one  finds  in  the  interval  with  no  pain  that  the  feces, 
are  filled  with  more  or  less  extensive  shreds  of  mucus,  having  numer- 
ous epithelial  cells  embedded,  which,  it  is  true,  at  times  are  more  or- 
less  dependent  on  an  emotional  influence  and  which  may  increase  until 
it  far  exceeds  in  quantity  the  feces  eliminated.  This,  to  us,  indicates  a 
low  degree  of  colon  catarrh,  and  while,  as  Da  Costa  and  others  main- 


462  DISEASES   OF    THE   DIGESTIVE    TRACT 

tain,  the  emotions  play  an  important  part,  they  cannot  originate 
mucous  or  membranous  colitis — whichever  one  chooses  to  call  it — for 
they  are  one  and  the  same.  A.  Schmidt  compares  the  relation  existing 
as  closely  allied  to  that  of  bronchitis  and  asthma.  There  is  a  con- 
stant secretion  of  mucus,  though  it  may  not  be  of  sufficient  amount  to 
annoy  the  patient,  but  from  some  emotional  cause  the  muscular  struc- 
ture of  the  bronchi  is  thrown  into  temporary  contraction  or  spasm, 
and  there  is  a  flood  of  mucus  eliminated.  Many  French  and  American 
authors  would  prove  a  close  connection  between  intestinal  gravel  or 
sand  and  mucous  colitis,  making  both  a  manifestation  of  uric  acid 
diathesis,  but,  as  the  sand  is  almost  always  made  up  of  calcium  phos- 
phate, carbonate,  and  oxalate,  stained  with  hydrobilirubin,  and  not  of 
uric  acid  at  all,  and,  furthermore,  constant  examination  will  bring  to 
light  as  many  instances  of  intestinal  sand  where  no  mucus  exists  as 
vice  versa,  such  ground  is  not  tenable.  The  thickened  bands  (mem- 
branous), which  are  often  so  opaque  that  they  are  unfitted  for  micro- 
scopic examination  without  sectioning,  do  not  differ  from  ordinary 
mucus,  according  to  A.  Schmidt,  except  that  9  to  10  per  cent  of  fat 
is  impregnated  in  their  substance.  This  form  is  not  soluble  as  ordi- 
nary mucus  is,  but  is  coagulated  like  the  shriveled  epithelial  cells.  No 
change  has  taken  place,  however,  in  the  excretive  action  of  the  colon, 
except  an  exaggeration  of  this  normal  function  of  fat  elimination. 
The  most  active  cause  of  this  variety  of  colitis  is  functional  constipa- 
tion, particularly  that  form  associated  with  spasm  of  this  section  of 
the  intestine.  The  irritating  action  of  dried  feces  in  producing  spasm 
has  been  described  under  constipation,  to  which  reference  is  made. 
Others  believe  that  the  spasm  is  produced  by  a  colitis  from  other  causes 
and  often  produces  the  constipation.  This  cannot  be  absolutely  de- 
nied, and  there  is  every  reason  to  believe  that  we  have  a  vicious  circle, 
the  constipation  aggravating  the  spasm  and  this,  in  turn,  delaying  the 
passage  of  feces.  Another  well-recognized  cause  of  membranous  colitis 
is  the  displacements  and  distortions  of  the  colon,  which  are  so  com- 
monly associated  with  similar  displacements  and  pathological  condi- 
tions of  the  genital  organs  in  women,  which  make  that  sex  a  participant 
in  this  disease  to  the  extent  of  75  to  90  per  cent.  Strange  to  say,  too, 
the  genital  disease  is  always  looked  on  as  the  sole  pathological  condition 
present,  and  the  profession  is  disappointed  when  a  radical  removal  of 
tubes  and  ovaries  fails  to  cure  the  symptoms.  On  account  of  the  inti- 
mate association  of  nerves  and  blood  vessels  of  both  uterus,  adnexa, 
and  colon,  we  may  consider  the  affection  of  the  genital  organs  as 
primary,  but  closely  allied  to  the  colon  in  all  neuroses.     Again,  one 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  ^3 

often  notes  the  presence  of  a  mucous  colitis  with  a  deep  urethritis  from 
gonorrheal  origin  or  from  a  persistent  pyelitis  and  nephroptosis. 
Others  arise  from  self -abuse  of  enemata  in  treating  constipation,  par- 
ticularly in  cases  where  4  quarts  of  water  are  introduced  by  the  widely 
advertised  ' '  cascade ' '  or  internal  bath.  Two  of  these  have  come  under 
our  observation  and  we  doubt  not  there  are  many  others.  In  some  in- 
stances, of  course,  this  condition  arose  from  an  acute  attack,  which 
was  so  far  back  that  the  patient  cannot  remember  the  particulars. 
Others  have  maintained  that  mucous  colitis  arises  from  a  chronic  ap- 
pendicitis, but  in  our  opinion  the  reverse  is  true — that  any  person  suf- 
fering from  chronic  catarrh  is  more  liable  to  inflammation  of  the  ap- 
pendix ;  at  least  the  removal  of  the  appendix  never  relieves  any  case  of 
mucous  colitis. 

Symptoms. — The  symptoms  are  much  varied,  and  have  a  different 
course  according  to  the  nervous  susceptibility  of  the  patient.  As  a 
rule,  they  come  on  very  gradually,  and  only  a  few  can  recall  an  acute 
attack.  There  are  periods  of  comparative  freedom  from  discomfort 
and  then  an  interval  is  interposed  when  the  patient's  declaration  is 
that  "life  is  a  burden."  Practically  all  the  victims  describe  periods 
of  constipation,  and  state  that,  as  soon  as  these  set  in,  the  pain  and  dis- 
charges of  mucus  are  markedly  increased.  Women,  too,  complain  of  an 
increase  in  discomfort  during  menstruation,  while  others  declare  that 
any  emotional  influence — anger,  sorrow,  or  disappointment — increases 
the  severity,  showing  a  strong  nervous  element.  It  becomes  manifest 
by  rumbling  of  the  bowels,  a  feeling  of  fullness,  which  the  patient  de- 
clares to  be  due  to  gas,  though  his  abdomen  is  flat  or  concave-shaped, 
and  a  feeling  of  insufficient  defecation,  or  often  actual  pain  in  some 
portion,  like  the  flexures.  Again,  actual  colics  occur,  which  at  first  are 
diffieult  to  differentiate  from  gallstone  or  appendical  colics.  Patients 
tell  us  that  their  pain  is  constant,  unaffected  by  the  amount  or  char- 
acter of  the  food,  but,  though  they  have  an  excellent  appetite,  they  are 
afraid  to  eat  to  satisfaction,  and  most  of  them  are  thin  and  apparently 
undernourished.  The  abdomen  is  an  obsession  with  them,  and  a  con- 
stant observation  of  the  stool  (which  is  their  custom)  does  not  relieve 
in  any  way  their  overexcitable  nervous  system.  The  sharp  attacks  of 
pain,  from  which  some  do  not  suffer,  but  have  a  dull,  steady  pain,  are 
dreaded  more  than  anything  else,  and  many  attacks  occur  without  any 
warning  or  preceding  restriction  of  stool.  At  first,  before  the  pain 
has  reached  its  climax,  the  sufferer  can  localize  it  in  the  right  (  ascend- 
ing) or  left  (descending)  abdomen  or  in  the  median  line  (transverse 
colon),  but  after  a  time  it  streams  over  the  entire  abdomen,  cold  sweat 


464  DISEASES  OP   THE  DIGESTIVE   TRACT 

covers  the  brow  and  face,  and  they  roll  on  the  floor  or  bed,  pressing 
their  hands  over  the  epigastrium  or  lower  down.  During  these  at- 
tacks of  pain  the  abdomen  is  not  distended,  but  rather  contracted,  as 
in  lead  colic,  nor  is  tenderness  so  pronounced  that  one  cannot  indulge 
in  deep  palpation.  Rapid  pulse  and  pinched  features  are  wanting, 
so  that  there  can  be  no  peritoneal  involvement.  During  the  colic — 
but,  better,  in  the  intervals — long  stretches  of  contracted  colon  can  be 
detected  and  rolled  under  the  fingers,  while  before  them  such  portions 
of  the  colon  are  soft  and  elastic,  and  gurgling  can  be  heard  and  gushes 
of  fluid  felt.  The  cecum  is  apt  to  be  found  relaxed,  while  th£  sigmoid 
is  almost  invariably  in  a  state  of  firm  contraction.  The  stomach,  too, 
may  be  found  somewhat  lowered  and  succussing  readily,  while  either 
one  or  both  kidneys  are  prolapsed,  and  in  women  the  ovaries  are  tender. 
The  introduction  of  the  reetoscope  is  occasionally  difficult  on  account 
of  spasm  of  the  lower  colon,  but  oftener  can  be  introduced  to  the  dis- 
tance of  25  cm.  without  any  trouble,  owing  to  the  relaxation,  which  we 
suspect  may  be  due  to  the  enormous  enemata  which  these  victims  some- 
times employ,  as  explained.  Some  boast  that  they  can  introduce  4 
quarts  into  the  bowel.  No  redness  or  ulcerations  can  be  discovered  in 
the  lower  colon,  since  the  process  is  ordinarily  higher  up. 

The  examination  of  the  stools  should  not  be  limited  to  one,  but  sev- 
eral examinations,  when  the  complaints  of  the  patient  in  regard  to 
scanty  defecation  are  found  to  be  justified.  No  formed  stool  is  usually 
found,  but  the  feces  are  made  up  of  small  dried  scybala.  Exception- 
ally, however,  a  change  to  semisolid  or  even  liquid  stools  may  take 
place,  but  only  temporarily,  and  those  burdened  for  a  long  period 
with  this  disease  will  state  that  not  for  years  have  they  had  a  formed 
stool.  Even  if  the  stool  is  formed,  instead  of  a  large  cylinder,  more 
or  less  coherent,  it  will  be  found  to  be  made  up  of  bands  and  lead- 
pencil-like  masses,  which  fall  apart  as  soon  as  the  stool  is  passed ;  the 
color  is  dark  and  the  odor  not  fetid,  unless  there  is  much  decomposing 
mucus  in  it.  In  uncomplicated  cases  no  food  remnants  will  be  discov- 
ered, though  occasionally  one  finds  numerous  fatty  acid  needles,  which 
indicate  an  intestinal  indigestion,  but  not  in  any  degree  an  enteritis. 
The  most  suggestive  thing  visible  is  the  mucus,  which  is  always  more 
excessive  after  a  colic,  when  the  entire  stool  may  be  made  up  of  bands 
of  mucus  (tapeworm  form) ,  with  scarcely  a  fragment  of  fecal  matter. 
Rarely,  however,  is  this  extreme  reached,  but  usually  out  of  the  mass 
of  macerated  feces,  suspended  in  water,  one  can  remove  large  gray  or 
colorless  masses  of  mucus,  either  clear  as  crystal  or  cloudy  (fat) ,  The 
softer  the  stool,  the  more  thoroughly  is  the  mucus  mixed  with  fecal 


INFLAMMATORY   DISEASES   OF   THE   INTESTINE  465 

material,  and  naturally  the  latter  condition  presages  a  higher  site  in 
the  colon  for  the  origin  of  the  mucus.  This  mucus  is  differentiated 
from  that  derived  from  the  small  intestine  by  having  no  food  frag- 
ments attached,  and  by  the  fact  that  its  epithelial  cells  are  well  re- 
tained instead  of  the  mere  presence  of  nuclei  alone.  These  variations 
in  the  character  of  the  stool  depend  largely  on  the  site  of  the  dis- 
turbance. If  the  upper  reaches  of  the  colon  are  affected,  the  stools 
are  liquid  and  the  mucus  exists  in  small  fragments;  if  the  lower,  the 
stools  are  solid  and  the  mucus  is  found  in  long  bands.  Then  there  ma^ 
be  periods  when  no  mucus  at  all  is  discovered,  and  these  periods  usuall> 
accompany  the  remissions  when  the  discomfort  of  the  patient  is  less. 
Pericolitic  involvements  of  mucous  colitis  must  be  rare.  Still,  cases 
have  come  under  our  observation  where  the  x-ray  showed  marked  delay 
of  the  bismuth  at  the  flexures,  and  exploratory  operation  demonstrated 
adhesions,  even  when  no  history  of  acute  colitis  could  be  obtained.  It 
is  always  well  to  bear  in  mind  the  possibility  mentioned  of  exacerba- 
tion of  the  colon  catarrh  in  ease  of  pyelitis  or  renal  stone,  and,  when 
pain  is  markedly  fixed  on  one  side  of  the  abdomen  or  the  other,  the 
urine  must  be  carefully  examined  for  this  complication.  The  patient's 
general  health,  particularly  his  nutrition,  always  suffers,  and  the  vic- 
tims are  spare  and  thin.  Whether  this  is  due  to  impaired  absorption, 
which  is  improbable,  so  rarely  does  one  see  any  extensive  food  residue 
in  the  stools,  to  increase  of  temperature,  which  others  describe,  but 
which  we  have  never  seen,  or  to  fear  of  food  and  restricted  eating, 
cannot  be  positively  stated.  Our  opinion  is  that  the  last  is  the  real 
cause.  Further,  this  fear  of  eating  is  one  of  the  various  manifesta- 
tions of  an  unstable  nervous  system,  whether  the  cause  or  result  of 
the  colon  catarrh  is  still  in  dispute.  Only  in  marked  enteroptosis,  with 
occasional  excessive  discharges  of  mucus,  can  one  possibly  regard  the 
nervous  condition  as  primary  and  the  cause  of  the  disease. 

Diagnosis. — The  diagnosis  of  this  disorder  is  not  particularly  diffi- 
cult, except  in  elderly  people,  where  the  loss  of  flesh,  gurgling,  and 
localized  pain  may  lead  one  to  suspect  malignant  disease.  Here  a 
radiogram  is  of  great  aid,  because,  while  it  shows  delay  in  the  passage 
of  the  bismuth,  it  does  not  show  obstruction,  and  the  content  is  found 
to  make  its  way  through  the  spasmodically  contracted  portion  without 
any  lessening  of  the  stream,  though  the  narrowed  portion  can  be  seen. 
The  prospects  of  relief  are  fair,  but  the  prospects  of  cure  are  poor — 
placed  by  some  authors  as  low  as  50  per  cent.  Our  experience  can 
boast  of  no  cures  in  the  sense  that  no  recurrence  ever  takes  place, 
except  perhaps  where  in  an  instance  or  two  a  surgical  operation  re- 


466  DISEASES  OF   THE   DIGESTIVE    TRACT 

lieved  the  patients  of  their  constipation  and  discharge  of  mucus,  but 
the  hypochondria,  which  is  often  most  distressing  to  the  patient  and 
his  friends,  is  very  reluctant  to  let  go. 

Treatment. — The  treatment  is  best  begun  by  keeping  the  patient  in 
bed  and  attempting  to  overfeed,  so  as  to  overcome  the  undernutrition, 
which  always  exists.  Then,  too,  strange  to  say,  the  movements  of 
the  bowels  will  sometimes  take  place  spontaneously  from  the  rest,  and 
relaxation  of  the  nervous  system.  When  acute  attacks  of  pain  occur, 
a  hypodermic  of  morphine  is  about  the  only  means  that  will  check  it, 
and,  after  the  pain  subsides,  one  can  proceed  to  the  real  treatment. 
This  consists,  first,  of  a  rigidly  controlled  diet,  which  should  employ 
the  fruit  juices — grape,  orange,  grapefruit,  cider,  etc. — sugar  of  milk, 
honey,  molasses,  and  articles  of  food  containing  salt.  Another  point 
to  be  observed  is  that  the  diet  must  be  ample.  At  least  three  large 
and  three  small  meals  should  be  taken  daily,  which  both  increase  the 
nutrition,  a  much  needed  desideratum,  and  also  produce  a  more  copious 
mass  of  feces,  which  aids  intestinal  peristalsis.  To  accomplish  this 
purpose,  one  has  to  use  much  persuasion,  because  the  patients  all  have 
a  preconceived  notion  that  a  too  generous  diet  increases  their  distress, 
but  no  physical  evidence  of  injury  from  this  abundant  feeding  can  be 
detected.  Often  the  combination  of  ample  food  and  rest  in  bed  are 
sufficient  to  improve  very  decidedly  faulty  defecation  by  making  it 
more  regular,  and  under  these  influences  the  stools  become  once  more 
formed.  When  this  effect  is  not  prompt  and  the  delay  is  caused  by 
the  colon  spasms,  these  can  often  be  overcome  by  a  nightly  suppository 
of  extractum  belladonnae,  0.02  gram,  which  should  be  continued  even 
after  stools  occur  every  twenty-four  hours.  If  with  these  means  the 
stools  are  not  formed  and  regular,  there  should  follow  twice  a  week  a 
colon  washing  with  a  rectal  tube,  either  by  the  patient  or  the  physician, 
using  at  least  2  liters  of  tepid  water,  containing  either  a  teaspoonful 
of  sodium  bicarbonate  or  borax  in  divided  portions  of  about  250  c.c. 
each,  of  which  the  last  portion  should  be  allowed  to  remain  in  the 
colon,  and,  by  massage  in  the  direction  of  the  cecum,  caused  to  flow  as 
much  toward  this  point  as  possible,  and  retained  all  night.  In  case 
there  is  no  fecal  accumulation  in  the  rectum,  a  mild  laxative,  like 
cascara  sagrada,  tamarindien,  or  phenolphthalein,  should  be  used. 
The  oil  injections  of  Fleiner  have  been  used  by  us  faithfully  in  many 
cases  of  membranous  colitis,  but  with  varying  success.  IMan^y  report 
the  ejection  of  the  same  amount  of  oil  in  the  morning  without  fecal 
matter,  while  others  declare  their  dull  ache  at  the  flexures  has  been 
increased.     It  is  difficult  to  conceive  how  such  results  should  occur, 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  467 

unless  the  oil  increases  the  spasm  by  the  effort  to  pass  it  through  the 
narrowed  portion.  At  least  a  trial  may  be  made  twice  a  week  until 
it  is  found  that  no  relief  is  derived  from  its  use.  The  efforts  to  treat 
the  mucous  membrane  of  the  colon  directly  are  usually  made  with  a 
weak  starch  or  gum  arable  clyster  to  the  amount  of  a  cupful,  which 
should  contain  two  grams  of  bismuth  subgallate  or  ichthyol.  This  is 
to  be  introduced  very  slowly  into  the  rectum  and  allowed  to  remain 
as  long  as  the  patient  will  retain  it.  All  stronger  substances,  like 
silver  nitrate,  collargol,  etc.,  should  not  be  employed,  for  they  always 
increase  the  mucus  and  spasm.  Gentle  massage  will  often  reinforce 
other  means  for  the  control  of  this  disease,  and  faradism  has  also  been 
known  to  aid,  but  beware  of  the  use  of  either  of  these  means  exclusively 
to  the  rejection  of  all  other  methods.  The  almost  universal  hypo- 
chondria which  accompanies  this  disorder  cannot  be  managed  at  home. 
Of  that  there  can  be  no  doubt,  and  our  most  persuasive  powers  are  al- 
ways directed  toward  procuring  a  change  for  the  patient ;  whether 
it  shall  be  to  a  sanitarium  or  to  a  resort — North  in  summer.  South  in 
winter — depends  largely  on  the  patient's  circumstances.  If  the  pa- 
tient is  a  woman  and  is  found  to  be  suffering  from  some  disturbance 
of  the  uterus  or  ovaries,  these  should  be  treated  first  or  synchronously 
with  the  colon  disease.  After  a  long  period  of  fruitless  medicinal 
treatment,  one  thinks  of  surgery,  and  it  must  be  acknowledged  that  an 
implantation  of  the  lower  ileum,  either  in  the  sigmoid  or  lower  end 
of  the  descending  colon,  has  relieved  many — whether  by  first  correcting 
the  constipation  cannot  be  told.  Stitching  the  opened  appendix  in  a 
wound  in  the  abdomen  and  flushing  the  colon  through  this  has  proved 
valuable  in  dysentery,  but  in  our  opinion  is  worthless  in  membranous 
colitis.  Removing  existing  adhesions,  we  think,  is  worse  than  useless, 
as  they  are  sure  to  return,  either  at  their  original  site  or  elsewhere. 

ULCERATIVE  COLITIS. 

Ulcerative  colitis  (dysentery),  a  form  always  accompanied  by  copi- 
ous purulent  discharge  and  also  by  ulcers,  is  the  severest  phase  with 
which  we  have  to  do.  Ordinarily  the  cases  are  extremely  rare,  but 
during  the  return  of  our  troops  from  tropical  parts  a  few  came  under 
our  observation.  The  condition  was  called  at  that  time  "chronic 
dysentery,"  but  it  was  not  that,  for,  whatever  may  have  been  its 
origin,  at  the  stage  at  which  it  was  seen  no  specific  microorganism  could 
be  isolated  from  the  stools.  The  ulcers,  which  may  be  minute  or  as 
large  as  a  half  dollar,  are  always  multiple,  have  as  a  favorite  site  the 


468  DISEASES  OP   THE   DIGESTIVE   TRACT 

rectum  and  the  sigmoid,  but  have  been  found  as  high  as  the  entrance 
to  the  ileum. 

Symptoms. — The  symptoms  are  noted  for  their  remissions.  At- 
tacking the  young  or  middle  aged,  the  disease  will  subside  for  a  short 
time  only  to  break  out  again  with  renewed  vigor.  Its  onset  may  be 
acute,  oftener  subacute  or  gradual;  its  active  period  is  accompanied 
by  fever,  the  patient  becomes  anemic  and  loses  weight  rapidly.  The 
chief  subjective  symptom,  and  the  one  to  which  the  victim  ascribes 
his  improvement  or  his  greater  impairment  of  health,  is  the  number 
of  stools,  which  reaches  six  to  ten  daily.  With  the  increase  of  the 
discharge,  too,  the  amount  of  blood,  mucus,  and  pus  also  becomes 
greater.  These  numerous  movements  are  particularly  brought  to  the 
patient's  attention  because  of  the  blood,  though  ordinarily  unaccom- 
panied by  pain.  Further,  pain  of  any  kind,  either  persistent  or 
spasmodic,  is  usually  absent ;  in  fact,  no  painful  sensations  are  aroused 
until  the  inflammatory  process  invades  the  peritoneum,  producing 
pericolitis.  Objectively,  during  the  fever-free  period  we  note  in  our 
patient  the  pallor  and  emaciation.  While  the  victim  may  not  look 
particularly  thin  when  dressed,  the  prominent  ilia,  clavicles,  and  ribs 
indicate  the  great  loss  of  flesh.  The  pallor,  too,  is  justified  by  hemo- 
globin content,  as  low  as  40  per  cent.  The  appetite  is  usually  good, 
and  the  patient  does  not  complain  of  distress  or  eructations.  When 
the  abdomen  is  examined,  one  is  struck  by  its  concavity ;  it  slopes  from 
the  iliac  crests  to  the  vertebral  column,  on  which  its  surface  seems  to 
rest;  the  skin  has  lost  its  fat  and  will  stretch  like  a  piece  of  rubber; 
the  colon  is  tender,  particularly  at  the  sigmoid,  and  is  found  in  a  state 
of  spasm.  Earely  is  any  portion  relaxed;  in  fact,  in  one  sufferer, 
so  emaciated  was  he,  the  sigmoid  was  distinctly  visible  on  the  surface 
of  the  abdomen.  When  with  the  aid  of  a  cocaine  solution  (20  c.c.  of 
1  per  cent)  the  rectoscope  can  be  introduced,  the  entire  lower  colon  is 
found  intensely  injected,  filled  with  granulations,  which  bleed  on  the 
slightest  movement  of  the  tube,  and  numerous  ulcerations  can  be  dis- 
tinctly seen. 

The  feces  are  distinguished,  first,  by  the  blood,  which  may  be  so 
excessive  that  it  may  be  called  a  "bloody  stool";  then,  too,  pus  is 
present  in  appreciable  quantities,  and  here  lies  the  most  distinguish- 
ing proof  of  the  ulcerations,  though  Rosenheim  declares  that  pus  may 
be  present  without  ulcers ;  leucocytes  are  in  a  state  of  fatty  degenera- 
tion and  often  show  vacuoles;  mucus,  too,  is  present  in  shreds  and 
bands,  but  the  more  apparent  it  is  the  more  scanty  are  the  pus  and 
blood.     When  the  process  extends  well  up  to  the  cecum,  the  odor  is 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  469 

often  putrid,  but  ordinarily  the  stools  are  odorless.  It  is  rare  that  any 
food  remnants  are  found  in  the  feces,  unless  occasionally  starch  when 
vegetable  food,  improperly  prepared,  is  ingested.  When  an  acid  re- 
action is  present,  the  lower  ileum  in  this  case  is  not  above  the  suspicion 
of  participation.  The  bacteriological  examination  of  the  stools  has 
never  shown  any  uniformity  in  the  species  found  predominating. 
Probably  the  colon  bacillus  is  the  most  prominent,  but  it  is  generally 
conceded  that  its  presence  is  secondary,  and  Zweig  alone  is  willing  to 
hold  a  peculiarly  virulent  form  as  responsible  for  the  ulcers,  but  he 
says  there  must  be  a  concomitant  colon  catarrh. 

The  complications  of  ulcerative  colitis  are  often  severe.  Besides  the 
invasion  of  the  peritoneum  and  local  perisigmoiditis,  general  peritoni- 
tis, with  fatal  termination,  has  arisen  from  it.  Thrombosis  of  the 
femoral  veins,  polyarthritis,  and  endocarditis  may  occur.  ]More  re- 
cently, too,  the  ulcers  have  been  shown  by  the  radiogram,  in  which  the 
smooth  contour  of  the  content  at  the  site  of  the  ulcers  is  broken. 

Diagnosis. — The  diagnosis  comprises  chiefly  the  differentiation  from 
mucous  colitis,  which  is  not  difficult.  The  scanty  mucus  or  absence 
of  mucus  can  be  utilized,  and  the  presence  of  numerous  leucocytes 
means  either  the  rupture  of  an  adjacent  abscess  into  the  canal,  a 
dysentery,  or  an  ulcer.  The  first  possibility  can  usually  be  eliminated 
by  palpation,  w^hich  will  locate  an  abscess  of  any  size.  If  the  abscess 
is  low  down,  a  digital  examination  by  the  rectum  will  usually  disclose 
it.  True  dysentery  can  be  excluded  only  by  the  absence  of  its  peculiar 
microorganism  (Flexner  bacillus).  The  prospects  of  recovery,  tak- 
ing into  account  the  complications,  are  rare.  A.  Schmidt  places  them 
at  50  per  cent,  but,  of  the  three  cases  under  our  observation  for  a 
long  time,  one  died  and  two  improved,  but  the  latter  drifted  out  of 
our  care  before  complete  recovery  had  taken  place. 

Treatment. — The  treatment  can  rely  very  little  on  dietetic  aid  un- 
less food  particles  are  found  in  the  stool,  Avhich,  as  stated,  is  uncom- 
mon on  account  of  the  rare  involvement  of  the  small  intestine.  The 
withdrawal  or  diminution  of  the  carbohydrates  in  the  food  when 
starch  granules  and  microbes  containing  granulose  are  found,  checks 
to  a  certain  extent  the  diarrhea,  but  the  result  is  temporary,  and  a 
return  to  free  carbohydrate  diet  soon  causes  the  recurrence  of  the 
numerous  stools.  Rosenheim,  on  the  contrary,  regarding  the  putrid 
odor  as  due  to  faulty  albumin  digestion  instead  of  the  presence  of 
foreign  elements  (pus  and  blood),  as  it  probably  is,  withdrew  prac- 
tically all  albumin  from  the  diet  and  fed  his  patients  on  milk  and 
flour  products.     His  success  was  only  a  limited  one,  but  shows  that 


470  DISEASES   OF   THE   DIGESTIVE   TRACT 

colitic  processes  may  be  aggravated  by  intestinal  indigestion,  and 
should  be  managed  as  it  is  as  far  as  diet  is  concerned.  Every  article 
of  diet,  however,  must  be  offered  in  its  most  minute  form,  so  that  ab- 
sorption may  be  hastened  and  as  little  residue  as  possible  allowed  to 
enter  the  colon. 

The  medicinal  treatment  is  still  confined  to  a  few  favorite  prepara- 
tions, from  which  too  much  must  not  be  expected.  Pulvis  ipecacu- 
anha et  opii  or  the  tincture  of  the  same  may  be  used,  in  doses  of 
0.6  gram  (10  grains  or  mms.)  three  times  daily,  or  bismuth  sub- 
salicylate, tannigen,  or  tannalbin  in  half -gram  (8-grain)  doses  may  be 
employed.  Colon  washings  with  solution  of  boracic  acid  (2-4  per 
cent),  salicylic  acid  (1:500),  hydrogen  peroxide  (1-2  per  cent),  or 
suspensions  of  bismuth  subcarbonate  or  subgallate,  may  be  used,  2 
grams  to  the  liter.  Tannin  and  silver  nitrate  have  never  been  em- 
ployed by  us  since  Boas'  warning  against  their  use.  All  of  these 
substances  are  much  more  effective  when  employed  through  the  ap- 
pendical  fistula.  "When  passed  into  the  tract  with  a  colon  tube,  it 
is  much  better  to  dissolve  or  suspend  the  medicinal  agent  in  a  starch 
or  gum  arable  clyster,  add  a  few  drops  of  laudanum,  and  never  use 
more  than  a  cupful.  All  efforts  to  use  larger  quantities  and  thus  dis- 
tend the  colon,  so  that  the  remedial  fluid  will  enter  all  the  interstices, 
as  it  is  described,  are  invariably  harmful  rather  than  beneficial.  Of 
the  treatment  through  the  rectoscope  with  dry  powders  blown  in  with 
a  powder  blower,  we  have  had  no  experience.  If  the  ulcerative  process 
is  low  down,  within  27  cm.  of  the  sphincter,  it  may  be  applicable,  but, 
if  higher  up,  as  it  often  is,  no  apparent  good  can  come  of  it.  Here, 
after  medicinal  means  have  been  exhausted,  we  must  proceed  to  surgi- 
cal intervention,  which  consists  in  either  an  artificial  anus  at  the  cecum, 
or,  on  account  of  the  annoyance  of  liquid  stools,  at  the  descending  colon. 
Both  of  these  operations  are  intended  to  free  the  portion  of  the  colon 
below  it  of  fecal  matter,  and  can  also  be  used  for  flushing ;  this  opera- 
tion counts  many  cures  to  its  credit.  The  various  anastomoses  of 
the  ileum  to  the  midtransverse  colon,  sigmoid,  or  rectum  are  much  less 
effective,  for,  though  it  relieves  a  portion  of  the  colon  of  its  feces,  it 
leaves  no  means  for  treatment  of  the  ulcers  above  the  transplantation. 
The  establishment  of  a  cecal  valve  or  the  opening  up  of  the  appendix 
stitched  in  the  abdominal  wall,  which  does  not  have  the  disagreeable 
features  of  an  artificial  anus,  since  no  fecal  matter  escapes,  but  allows 
a  complete  flushing  of  the  colon  from  cecum  to  anus,  has  been  fully 
as  effective  as  when  the  feces  were  excluded.  Then,  again,  after  res- 
toration to  normal  is  established,  the  closure  of  this  small  aperture  is 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  471 

a  trifling  matter ;  hence  this  will  be  the  operation  of  choice  unless  some 
other  condition  makes  one  of  the  others  imperative. 

SIGMOIDITIS  AND  PERISIGMOIDITIS. 

Sigmoiditis  and  perisigmoiditis,  as  an  entity,  was  for  a  long  time  in 
doubt,  and  as  yet,  pathologically,  they  still  have  a  rather  weak  basis 
for  their  existence,  though  clinically  they  seem  well  defined.  In  the 
first  place,  this  condition  is  often  confused  with  proctitis  on  the  one 
hand,  and  may  spring,  on  the  other  hand,  from  the  mucous  membrane 
of  other  parts  of  the  intestine  by  extension  or  from  antecedent  gon- 
orrheal or  other  inflammation  of  the  ovaries  in  women.  Still,  the  sig- 
inoid,  on  account  of  its  tortuous  course.,  its  freedom  of  movement,  its 
thick  muscular  walls  with  narrow  lumen,  and  its  constant  content  of 
thickened  fecal  masses,  seems,  like  the  cecum,  particularly  prone  to  in- 
flammatory processes,  produced  either  by  the  entrance  of  infectious 
bacteria  through  the  injured  mucous  membrane  or  the  irritation  pro- 
duced by  hardened  scybala.  The  position  of  chronic  sigmoiditis,  how- 
ever, is  much  better  assured  than  that  of  acute,  and  has  long  been 
known  from  its  surgical  aspect.  Its  chief  characteristic  is  swelling 
of  such  an  extent  and  of  such  firmness  that  it  is  often  mistaken  for 
cancer  and  operated  under  that  false  diagnosis.  Here,  too,  the  mucous 
membrane  injury  is  of  little  import,  but  the  thickening  about  the 
intestine  is  so  great  that  obstruction  occurs,  or  abscesses  may  form,  as 
in  the  acute,  and  break  into  the  intestine  or  bladder,  or,  as  in  one 
case,  under  our  observation,  into  both,  so  that  feces  and  flatus  were 
passed  by  means  of  the  urethra.  Further  investigation  of  the  pathol- 
ogy of  this  disease  has  showni  that  small  perforations  of  the  muscular 
coat  exist  in  this  region,  by  which  pockets  are.  formed  by  the  mucous 
membrane  extending  through  these  and  resting  on  the  peritoneal  layer, 
in  which  the  decomposing  fecal  particles  set  up  serous  inflammation. 
Of  course  this  limited  sigmoiditis  must  be  differentiated  from  tubercu- 
losis, syphilis,  and  dysentery  of  other  parts  of  the  colon  which  have 
invaded  the  sigmoid. 

Symptoms. — The  symptoms  of  the  acute  form  resemble  very  closely 
a  destructive  appendicitis,  but  on  the  left  side ;  in  fact,  a  true  appendi- 
citis may  cause  an  extension  of  the  inflammatory  process  to  the  perisig- 
moid  region,  or,  rarely,  the  cecum  may  be  found  lying  on  the  left  side. 
The  disease  begins  with  fever  and  intense  pain  on  the  left  side,  which 
may  or  may  not  be  preceded  by  a  longer  or  shorter  period  of  constipa- 
tion.    In  mild  cases  which  do  not  go  on  to  abscess  formation  there 


472  DISEASES   OF   THE   DIGESTIVE   TRACT 

may  be  no  fever,  nor  any  of  the  signs  of  severe  peritonitis,  vomiting, 
meteorism,  and  collapse,  but  extreme  tenderness  and  a  moderate  spasm 
of  the  superficial  muscles.  The  sigmoid  can  always  be  felt,  however, 
as  a  tender,  sausage-like  mass,  lying  along  the  left  iliac  and  followed 
wdth  the  fingers  into  the  lesser  pelvis.  The  bowels  are  usually  con- 
fined, and,  when  stool  is  either  spontaneous  or  induced  by  enema,  the 
feces  are  made  up  of  small  hardened  balls,  covered  with  mucus,  which 
is  either  blood  stained  or  mixed  with  pus.  Under  appropriate  treat- 
ment the  tumor  usually  subsides,  but  it  may  increase  and  terminate  in 
an  abscess  outside  of  the  sigmoid,  with  severe  general  symptoms,  chills, 
vomiting,  etc.  In  still  severer  cases  the  perisigmoiditic  or  peritonitic 
symptoms  prevail  almost  from  the  start;  the  pain  does  not  remain 
confined  to  this  locality,  but  shoots  into  the  left  leg  and  bladder,  the 
least  movement  causes  pain,  and  even  urination  is  painful  and  scanty ; 
the  patient  vomits  once  or  twice,  the  face  is  sunken,  and  the  extremi- 
ties are  cold  and  bloodless.  The  danger  of  a  general  peritonitis  is 
much  less  in  sigmoiditis  than  in  appendicitis.  Usually  the  affected 
area  is  quickly  walled  off  from  the  general  peritoneum,  the  exudate  is 
easily  mapped  out  by  palpation,  is  painful,  and,  unless  relieved  by 
surgical  means,  the  pus  may  make  its  way  into  the  various  cavities  in 
the  immediate  vicinity,  A  third  way  is  open  to  the  abscess  contents, 
absorption,  which  has  often  occurred,  but  it  presents  too  many  risks  to 
be  voluntarily  chosen,  and  frequently  leaves  sigmoid  strictures  behind. 
The  chronic  form  steals  in  without  any  temperature  or  violent  suf- 
fering, and  is  usually  well  established  when  discovered ;  yet,  whenever 
an  abscess  forms,  we  have  the  same  train  of  symptoms  as  follows  a 
similar  occurrence  after  the  acute  form.  The  chronic  form  is  more 
likely  to  arise  after,  if  not  from,  a  long  period  of  constipation,  acute 
dysentery,  or,  what  is  remarkably  common,  after  an  appendicitis, 
whether  operated  or  not.  The  patient  usually  comes  with  the  story 
of  increasing  difficulty  in  securing  a  daily  stool,  with  now  and  then  an 
attack  of  diarrhea,  accompanied  by  much  "slime."  as  he  terms  it, 
which  may  or  may  not  be  blood  stained,  and  increasing  pain  in  the 
left  lower  abdominal  region,  which  may  become  colicky.  The  sufferer, 
in  spite  of  ample  food,  is  thin,  having  lost  much  flesh,  and  feels  weak 
and  sick.  Unless  some  of  the  complications  mentioned  have  occurred, 
the  manifestations,  apart  from  these,  are  wholly  local.  On  palpation 
of  the  seat  of  the  pain,  the  sigmoid  can  be  easily  felt  of  greater  or  less 
dimensions — ^hard,  smooth,  and  well  defined,  or  its  outline  fading  off 
into  the  surrounding  tissues  (perisigmoiditis).  The  sigmoid  has  lost 
to  a  large  extent  its  motility  or  may  be  firmly  fixed,  while  ver\^  often 


INFLAMMATORY   DISEASES   OP   THE   INTESTINE  473 

hardened  fecal  masses  may  be  felt  in  the  adjoining  portion  of  the 
colon  above.  Eectal  or  bimanual  examination  offers  no  light,  since  no 
obstruction  of  the  lumen  is  found,  nor  can  we  determine  whether  there 
is  simply  a  thickening  of  the  intestinal  wall  or  an  adjacent  tumor. 
Under  ether  the  hardness  of  the  mass  may  subside  somewhat  because 
it  is,  partially  at  least,  due  to  spasm,  but,  as  anesthetics  do  not  always 
subdue  intestinal  spasm  fully,  we  dare  not  rely  oh  this  test  alone.  The 
feces  offer  but  little  light ;  they  are  usually  hard  and  in  lumps,  but  may 
be  semisolid.  When  hard,  they  are  generally  in  small  balls  or  of  small 
caliber,  indicating  the  narrowing  of  the  gut  at  its  lower  portion.  This 
is  consistent  with  the  sense  of  fullness  and  frequent  defecation  with 
the  deficient  stools  of  which  the  patient  complains.  Mucus  is  abun- 
dant and  often  blood  stained,  or  red  blood  corpuscles  may  actually  be 
found.  Furthermore,  the  feces  never  contain  any'  food  remnants,  and 
do  contain  evidences  of  inflammation  of  the  lower  colon  in  the  shape 
of  mucus  and  blood  or  blood-stained  shreds  of  the  same.  By  these 
features  and  their  sudden  change  of  character  we  may  distinguish  this 
condition  from  simple  colitis,  but  much  less  easily  from  cancer. 

The  rectoscope  also  furnishes  great  aid  in  the  detection  of  this  con- 
dition. While  the  mucous  membrane  of  the  rectum  shows  no  change 
as  we  approach  the  rectopelvic  angle,  we  find  the  surface  is  reddened, 
bleeds  easily,  and  shows  small  erosions  which  are  covered  with  mucus. 
At  the  same  time  the  passage  narrows,  and  the  air  which  is  blown  in 
fails  to  enlarge  the  caliber,  so  that  it  is  often  impossible  to  reach  the 
flexure;  when,  by  care,  this  is  accomplished  and  the  tube  inserted  a 
distance  of  30  cm.,  the  reddening  can  be  seen  to  have  begun  to  dis- 
appear, indicating  a  purely  local  process. 

Diagnosis. — The  diagnosis,  apart  from  confusion  of  a  localized  proc- 
ess with  a  general  one,  chronic  mucous  colitis  or  dysentery,  may  be  con- 
founded with  a  local  abscess  arising  from  inflammation  of  the  adnexa 
in  women,  as  in  a  case  under  our  observation,  where  pain  on  the  left 
side,  frequent  loose  movements  containing  mucus,  and,  later,  leucocytes 
with  much  tenesmus  and  a  pyemic  temperature,  led  to  a  diagnosis  of 
perisigmoiditis,  which  operation  showed  to  be  a  suppurating  dermoid 
cyst  adherent  to  the  sigmoid  and  at  that  time  discharging  into  it. 
Then,  too,  there  is  the  constant  danger  of  confusing  early  cancer  with 
chronic  sigmoiditis  in  elderly  people,  and  the  best  means  of  settling  this 
question  is  by  the  use  of  the  rectoscope.  A  livid  color  of  the  mucous 
membrane  and  much  edema  is  in  favor  of  malignant  disease,  though  no 
firm  epithelial  new  growth  is  found.  Furthermore,  the  rigid  resist- 
ance offered  to  the  further  introduction  of  the  tube  after  repeated 


474  DISEASES   OF   THE   DIGESTIVE   TRACT 

efforts  increases  the  likelihood  of  the  same  pathological  condition.  On 
the  contrary,  a  marked  disproportion  between  the  size  of  the  mass  to 
the  symptoms,  its  smooth  surface,  and  lack  of  motility  are  significant 
of  pure  inflammation  rather  than  malignant  disease.  It  is  a  well- 
recognized  fact  that  there  may  be  pericolitic  inflammation  with  ad- 
hesions in  any  part  of  the  colon,  but  these  differ  from  perisigmoiditis 
in  that  there  is  vastly  greater  disturbance  of  the  mucous  membrane 
in  the  former;  in  fact,  we  might  assume  that  perisigmoiditis  may  exist 
de  novo  at  times  did  we  not  know  that  the  infection  comes  from  the 
lumen  of  the  tract.  In  the  rest  of  the  colon  these  stricture-forming 
external  inflammatory  processes,  as  are  found  at  the  sigmoid,  rarely 
occur  except  at  the  cecum  and  the  adjoining  ascending  colon. 

Treatment. — The  treatment  must  necessarily  vary  with  the  form 
and  severity  of  the  disease.  If  a  simple  sigmoiditis,  one  can  treat  it 
the  same  as  a  catarrhal  appendicitis — by  rest  in  bed,  liquid  diet,  an  ice 
bag  or,  when  this  is  objectionable  to  the  patient,  an  electric  pad  applied 
to  the  painful  region.  It  is  much  better  to  empty  the  bowels  with 
enemata  of  oil  and  soap  suds,  or  oil  alone,  rather  than  by  laxatives. 
Castor  oil  should  not  be  employed  unless  there  is  absolutely  no  danger 
of  a  rupture  of  an  abscess  and  the  patient  declares  that  a  long  period 
of  constipation  had  preceded  the  attack.  If  a  free  movement  has  been 
secured,  the  bowels  must  be  kept  open,  which  can  often  be  accom- 
plished by  the  liberal  use  of  fruit  juices  and  honey.  A  return  to  an 
unrestricted  diet,  particularly  to  those  articles  of  food  which  contain 
a  large  amount  of  cellulose — cabbage,  onions,  and  uncooked  vegetables 
like  lettuce,  radishes,  and  celery — should  be  deferred  as  long  as  pos- 
sible. "When  perisigmoiditis  occurs,  the  temperature  and  the  leucocyte 
count  should  be  followed  closely,  and  at  the  first  signs  of  suppuration 
a  surgeon  should  be  summoned  to  free  the  pus  as  soon  as  an  abscess  is 
discovered  in  order  that  perforation  into  bladder  or  general  peritoneal 
cavity  may  not  take  place.  In  chronic  cases  of  the  elderly,  exploratory 
operation  is  much  more  often  suggested  by  the  surgeon  for  fear  of 
malignancy.  Internal  treatment  has  been  proposed  for  the  chronic 
cases,  and  consists  either  of  the  clysters  containing  dermatol,  ichthyol, 
or  iodoform,  as  are  used  in  ulcerative  colitis,  or  the  use  of  these  pow- 
ders applied  directly  to  the  diseased  section  of  the  colon  through  a 
reetoscope  by  means  of  a  powder  blower  with  a  long  nozzle.  The  only 
effective  surgical  treatment  is,  naturally,  the  complete  resection  of  the 
diseased  portion,  but  this  is  often  so  difficult  and  so  jeopardizes  the 
patient's  life  that  a  preliminary  colostomy  above  the  sigmoid  is  per- 
formed, and,  by  irrigations  with  the  various  medicaments  mentioned, 


INFLAMMATORY   DISEASES   OF    THE   INTESTINE  475 

an  attempt  is  made  to  restore  it  to  its  normal  condition.  If  this  can- 
not be  done,  or  any  suspicion  of  malignancy  arises,  a  second  operation 
may  succeed  in  its  removal  and  the  patient's  life  be  saved. 

PROCTITIS  AND  PERIPROCTITIS. 

Proctitis  and  periproctitis  form  the  last  division  of  localized  inflam- 
mation of  the  large  intestine,  and,  while  now  the  diseases  of  the  lower 
section  of  the  colon  have  passed  largely  out  of  the  hands  of  the  gas- 
troenterologist  into  those  of  the  rectal  surgeon,  still  the  former  should 
have  at  least  a  working  knowledge  of  this  condition.  This  localized 
inflammation  is  only  to  the  slightest  degree  the  outcome  of  a  similar 
process  higher  up.  When  suffering  from  severe  diarrheas,  the  pa- 
tient often  complains  of  the  burning  in  the  rectum  and  anus,  and  of 
the  cramplike  closure  of  the  latter  after  each  movement.  This  is  un- 
doubtedly due  to  the  irritation  of  the  decomposed  inflammatory  prod- 
ucts, and  usually  disappears  after  the  attack  is  over,  but  may  persist 
as  a  result  of  hemorrhoids,  polypi,  fissure,  etc.  Hence  the  greatest 
number  of  attacks  of  proctitis  arises  from  local  irritation,  be  it  me- 
chanical, as  scybala,  retroversion  of  the  uterus,  which  rests  on  the 
rectum  in  women,  injury  from  hard  rubber  or  metal  rectal  tubes,  or 
unusually  irritating  enemata,  or  even  pinworms  and  the  consequent 
pruritus  and  scratching.  Or,  in  spite  of  the  fact  that  the  anal 
sphincter  closes  so  tightly  that  microorganisms  rarely  pass  through,, 
we  may  have  a  proctitis  set  up  by  gonorrhea,  particularly  in  women, 
by  extension  from  the  genitals,  which  does  not  differ  in  any  respect 
from  that  produced  in  other  ways.  In  men  it  is  much  less  common, 
and  may  be  explained  by  lack  of  cleanliness.  This  extension  is  most 
common  in  children,  and  in  the  acute  form  is  especially  painful  and 
distressing,  while  in  the  chronic  form  it  may  be  barely  noticed.  The 
mucous  membrane  of  the  rectum  seems  particularly  susceptible  to 
mechanical  injury,  as  can  often  be  noticed  by  simply  expanding  its 
folds,  thereby  causing  superficial  lesions.  Hence  small  ulcerations 
may  extend  through  the  muscular  coat  to  the  subserous  layer,  where 
small  abscesses  form,  which  may  break  into  the  rectum  again  or 
burrow  into  the  lax  tissue  about  the  rectum  and  form  the  so-called 
"fistulas,"  which  are  common.  Nor  does  the  injury  end  here,  for 
often  from  this  entrance  of  bacteria  may  spring  many  cases  of  peri- 
proctitis. 

Symptoms. — The  symptoms  in  the  acute  cases  begin  with  a  sense  of 
intense  fullness  in  the  rectum,  which  may  increase  to  paroxysms  and 


476  DISEASES   OP   THE   DIGESTIVE   TRACT 

with  pain,  which  streams  to  the  bladder,  genitals,  and  up  to  the  left 
lower  abdominal  region.  Sitting  is  impossible  and  walking  and  stand- 
ing painful,  so  that  the  patient  is  usually  forced  to  seek  his  bed. 
With  the  pain  begins  an  intense  desire  for  defecation,  which  innumer- 
able visits  to  the  lavatory  do  not  stay,  and,  in  fact,  after  a  time  no  fecal 
matter  passes,  though  the  tenesmus  remains  the  same.  At  first,  after 
strong  bearing  down,  the  anal  sphincter  is  opened  and  a  little  fecal 
matter  is  ejected,  but  more  often  only  intestinal  secretion.  The  dis- 
charge of  this  causes  intense  burning,  the  sphincter  closes  spasmodi- 
cally after  it,  and  the  tenesmus  begins  anew.  Very  often  this  tenes- 
mus is  imparted  to  the  bladder,  and  retention  or,  more  often,  frequent 
and  painful  micturition  adds  to  the  patient's  torture,  which  may  be 
increased  still  more  by  the  prolapse  of  the  rectal  mucous  membrane 
through  the  anal  opening.  The  general  health  suffers  also  on  account 
of  the  loss  of  sleep,  lack  of  desire  for  food,  and,  not  unusually,  a  slight 
feverish  attack,  which,  if  the  inflammation  is  confined  wholly  to  the 
mucous  membrane,  soon  subsides,  but,  if  continued  to  the  perirectal 
tissue,  may  be  of  some  duration. 

Physical  examination  by  the  eye  alone  may  show  only  a  slightly 
reddened  anal  opening,  ^nth  perhaps  hemorrhoids  and  a  small  fissure, 
which  are  only  complications.  "With  the  introduction  of  the  finger 
into  the  rectum,  which  is  often  difficult  and  sometimes  impossible  on 
account  of  the  spasmodic  closure  of  the  anal  sphincter,  one  feels  the 
mucous  membrane  hot,  extremely  sensitive,  and  covered  with  bloody 
mucus  or  with  a  bloody  purulent  secretion,  which  remains  attached  to 
the  finger  when  withdrawn.  When  the  rectoscope  can  be  introduced, 
which  is  sometimes  impossible,  but  should  always  be  preceded  by  a 
small  amount  of  1-2  per  cent  cocaine  solution,  the  reddened  mucous 
membrane  with  small  bloody  erosions  can  be  seen.  By  this  means  one 
gains  a  knowledge  of  the  severity  and  extent  of  the  process,  and,  if 
the  rectal  fold  can  be  reached,  one  notices  its  restriction  to  the  rectum 
alone.  The  feces  are  always  scanty,  and,  on  account  of  the  sphincter 
spasm,  are  ribbon-like  or  pencil-shaped.  When  delay  in  the  sigmoid 
has  occurred,  they  are  pebble-shaped  and  cause  exquisite  torture  when 
passed.  Very  often,  too,  they  are  covered,  but  not  mixed,  with  mucus, 
blood,  and  pus.  The  more  of  the  last  that  is  found,  the  more  severe  is 
the  process.  While  this  is  the  usual  appearance  on  account  of  the 
abundant  intestinal  secretion,  these  fecal  fragments  may  become  dis- 
solved or  liquefied,  and  real  diarrheal  stools  result.  If  due  to  gonor- 
rheal infection,  of  course  a  smear  of  the  pus  on  the  slide  when  stained 
readily  shows  the  gonococci.     When  the  process  extends  from  the 


INFLAMMATORY   DISEASES   OF   THE   INTESTINE  477 

mucous  membrane  to  the  surrounding  tissue,  a  marked  change  takes 
place;  the  symptoms  increase  in  severity,  the  temperature  rises,  chills 
may  be  present,  throbbing  occurs,  and  the  tissues  around  the  anus  be- 
come hard  and  brawny,  excessively  tender,  and,  when  an  abscess 
threatens  to  break  out,  raised  and  reddened.  If  about  to  point  in  the 
rectum,  the  finger  will  usually  discover  the  hardened  spot,  and,  if 
fluctuating,  surgical  aid  should  be  sought  at  once. 

The  chronic  form  is  usually  much  less  troublesome  and  much  more 
endurable.  There  is  fullness  in  the  rectum,  but  it  is  not  excessive,  and 
the  patient's  attention  is  first  called  to  his  illness  by  mucus  and  blood 
in  the  stools.  There  is,  however,  a  most  intolerable  pruritus,  which  is 
aroused  by  an  accompanying  anal  eczema.  After  long  duration  it  is 
found  that  the  sphincter  does  not  close  tightly  and  allows  a  certain 
amount  of  the  secretion  to  escape  with  the  flatus,  thus  producing  the 
eczema. 

Rectoscopic  examination,  which  in  the  chronic  form  is  never  difficult, 
shows  a  bluish-red  mucous  membrane,  with  prominences,  due  to  swell- 
ing of  the  follicles.  As  causes  we  have  oxyuris,  or  often  blind  fistulae, 
which  have  a  narrow  opening  into  the  intestine  above  the  sphincter. 

The  complications  and  sequelae  of  proctitis  consist  chiefly  of  hemor- 
rhoids. These  dilated  veins  about  the  anus  ordinarily  cause  little 
trouble,  rarely  bleeding  at  defecation,  but,  when  they  become  inflamed, 
form  hard,  painful  kernels,  and  microorganisms  pass  through  the  thin 
mucous  membrane  and  still  further  increase  the  irritability  of  the 
rectum.  In  addition,  by  the  passage  of  hard  stools  the  delicate  super- 
ficial layer  of  the  mucous  membrane  becomes  torn,  and  fissures  or, 
rather,  shallow  ulcers,  long  and  narrow,  result,  which  are  in  the  folds 
of  the  anus  and  can  usually  be  exposed  to  view  only  by  putting  the 
surface  completely  on  the  stretch,  so  that  these  folds  vanish.  This  act 
only  at  defecation  may  cause  any  pain.  These  fissures  are  often  very 
difficult  to  find  because  they  produce  a  sphincter  cramp,  which  in- 
creases the  folds  and  buries  them  still  deeper  in  the  sulci  formed.  Of 
course  above  the  anal  ring  they  cannot  be  found  except  with  the  aid 
of  the  rectal  speculum  or  rectoseope,  whose  introduction  must  always 
be  preceded  by  the  use  of  the  cocaine  solution  on  account  of  the  pain 
induced.  Even  the  smallest  of  these  may  produce  intense  pain  in  de- 
fecation, which  causes  the  sufferer  to  restrain  the  act  as  long  as  pos- 
sible, which,  in  turn,  aggravates  the  proctitis.  In  some  instances  the 
fissures  are  the  result  of  an  anal  eczema,  produced  by  the  discharge 
from  the  proctitis,  as  described,  combined  with  the  effects  of  scratch- 
ing. 


478  DISEASES   OF   THE   DIGESTIVE   TRACT 

From  the  periproctitis  we  have  the  fistiilte,  as  explained,  v\'hich  may 
open  into  the  rectum,  externally  beside  the  anus,  commonly  called  "in- 
complete," or  in  both  localities,  when  they  are  regarded  as  complete. 
These  are  always  discharging  a  small  amount  of  pus,  and  from  the  en- 
trance of  fecal  matter,  or  infectious  products,  may  penetrate  deep  in 
the  tissues.  Very  often  of  a  tubercular  nature,  they  cause  little  dis- 
comfort, but  are  instrumental  in  keeping  up  the  proctitis,  and,  innocent 
and  superficial  as  they  look,  the  introduction  of  a  flexible  probe  will 
show  deep  incursions  into  the  surrounding  tissues. 

Diagnosis. — The  diagnosis  should  never  rest  on  mere  inspection  and 
digital  examination,  for  by  these  means,  even  aided  by  the  ordinary 
rectal  speculum,  one  can  rarely  obtain  full  knowledge  of  the  condi- 
tion present.  With  an  inspection  of  the  stool,  however,  and  the  use 
of  the  rectoscope,  it  is  not  difficult  to  determine  the  severity  and  ex- 
tent of  the  disease.  At  the  same  time  this  gives  us  some  idea  of  the 
«ause,  whether  secondary  to  ulcerative  colitis,  dysentery,  tuberculosis, 
malignant  disease,  worms,  gonorrhea,  fissures,  or  fistulae.  "When  this 
has  been  determined  we  may  also  offer  some  opinion  as  to  the  out- 
come, which  is  usually  favorable  in  simple  catarrhal,  uncomplicated 
proctitis.  In  the  chronic  form,  one  comes  on  a  protrusion  of  the  lower 
portion  of  the  rectum  (prolapsus  ani),  caused  by  paralysis  of  the 
sphincter. 

Treatment. — The  treatment  consists,  first,  during  the  active  stage  of 
insisting  that  the  patient  remain  in  bed,  and,  second,  in  checking  the 
tenesmus  as  soon  as  possible  by  tinctura  opii  deodorati  in  doses  of  15 
drops  every  few  hours,  according  to  results,  or  a  suppository  of  bella- 
donna and  opium  may  be  used.  The  almost  incessant  straining  of  the 
patient  at  stool,  to  relieve  himself  of  what  he  regards  as  a  full  rectum, 
must  be  discouraged  as  much  as  possible  for  fear  of  a  rectal  prolapse, 
as  well  as  from  the  fact  that  the  congestion  is  always  increased  by 
this  act.  The  diet  should  be  largely  liquid,  as  completely  free  as  pos- 
sible from  residual  matter,  which  can  be  accomplished  by  straining  all 
the  food  given.  After  one  or  two  days,  when  the  tenesmus  has  some- 
what subsided,  which  can  also  be  aided  by  hot  hip  baths,  one  can  pro- 
ceed to  the  emploj'ment  of  enemata,  consisting  of  salt  solution 
(6:1,000),  or  flaxseed  tea,  used  in  quantities  not  larger  than  a  cupful 
at  a  time,  to  which  15-20  drops  of  laudanum  should  be  added.  Later 
the  regular  Fleiner  injections  of  sweet  oil  may  be  employed;  these 
should  always  be  only  tepid,  for  any  higher  temperature  causes  rapid 
rejection  by  the  inflamed  intestine.  After  the  severer  symptoms  have 
vanished,  we  may  proceed  to  treat  the  cause.     If  gonorrheal,  we  may 


INFLAMMATORY   DISEASES   OP    THE   INTESTINE  479 

use  protargol  suppositories,  0.02-0.1  gram  (%-l^  grains),  or  weak 
solutions  of  silver  nitrate  (1:3,000,  increasing  to  1:1,000)  through  a 
double  current  rectal  tube.  When  the  nonspecific  forms  have  not  dis- 
appeared in  from  eight  to  ten  days,  it  is  wiser  to  apply  the  dusting 
powders — dermatol,  iodoform,  etc. — through  the  rectoscope  than  to 
rely  on  the  astringent  injections,  where  one  cannot  see  what  is  being 
accomplished.  This  employment  of  powder  directly  is  peculiarly  the 
domain  of  the  chronic  form.  Fissures,  fistulae,  and  hemorrhoids  are 
amenable  only  to  surgical  treatment.  The  first  can  be  healed  by  com- 
plete stretching  of  the  sphincter  and  lightly  cauterizing  the  defective 
mucous  membrane.  The  second,  if  incomplete,  must  be  opened  freely 
and  drained;  if  complete,  must  be  laid  open  by  cutting  through  the 
sphincter  and  curetted.  The  last  must  be  treated  by  the  destruction  of 
each  nodule  with  the  actual  cautery,  which,  if  skillfully  and  not  too 
extensively  applied,  leaves  no  chance  for  subsequent  injury  and  rarely 
produces  stricture.  Many  still  treat  fissures,  while  the  patient  is  en- 
gaged in  his  daily  pursuits,  by  restraining  the  stool  several  days  and 
'by  a  daily  application  of  dusting  powder  (aristol,  calomel,  or  iodo- 
form) ;  then  by  a  large  dose  of  castor  oil  the  bowels  are  to  be  freed 
from  their  accumulation  and  kept  open  until  the  fissure  is  healed. 
This  method  is  adapted  only  to  superficial  breaks  in  the  mucous  mem- 
T)rane.  Hemorrhoids,  too,  have  been  treated  by  an  injection  of  each 
nodule  with  1-5  drops  of  a  glycerine-carbolic  acid  solution  (equal 
parts)  under  the  usual  antiseptic  precaution,  as  well  as  the  protection 
of  the  mucous  membrane  by  vaseline.  After  the  insertion  of  a  fine 
hypodermic  needle  into  the  piles  and  injection  of  the  solution,  the 
needle  should  remain  for  a  short  time  until  coagulation  of  the  blood 
has  taken  place.  Confinement  of  the  bowels  by  opium  for  three  days, 
and  then  a  free  purge  by  means  of  castor  oil,  usually  completes  the 
cure.  Whether  it  is  fully  safe  to  allow  the  patient  to  go  about,  or,  as 
some  advertise,  "without  detention  from  business,"  is  not  so  certain. 
At  least  the  safest  way  is  to  keep  the  patient  in  bed  during  this  treat- 
ment. 


CHAPTER  XVII 

ULCERATIVE  PROCESSES  OF  THE  INTESTINE  AND  THEIR 

SEQUELJC 

In  the  discussion  of  inflammation  we  have  come  on  ulcers,  as,  for 
instance,  in  the  colon  following  severe  colitis,  but  the  general  tendency 
of  all  such  processes  was  to  invade  the  peritoneum  and  eventually  cause 
adhesions.  Here  is  a  group  of  ulcers,  essentially  chronic,  whose 
etiology  is  still  rather  imperfectly  understood,  resembling  more  the 
gastric  ulcer,  which,  as  far  as  is  known,  never  arises  from  inflammation. 
The  general  causes  of  these  ulcers  may  be  stated  as,  first,  pressure  of 
the  hard  fecal  masses  on  the  mucous  membrane  in  the  rectum,  sig- 
moid, and  flexures  of  the  colon,  and,  second,  stretching  of  the  intestinal 
walls,  by  which  the  blood  supply  is  diminished;  or  embolism  of  the 
veins  may  occur,  both  leading  to  localized  necrosis,  which  accounts  bet- 
ter for  the  ulcers  of  the  cecum  where  the  stools  are  rarely  solid. 
Ulcers,  too,  may  occur  with  nephritis  in  the  lower  ileum  and  the  upper 
colon,  dependent,  as  is  supposed,  on  the  irritation  produced  by  am- 
monium carbonate,  arising  from  decomposing  urea,  which,  as  is  well 
known,  is  eliminated  largely  by  the  intestine.  Furthermore,  it  has 
long  been  believed  that  we  may  have  ulcers  from  burns  of  the  body, 
whose  favorite  site  is  the  horizontal  portion  of  the  duodenum;  ulcers 
from  septic  disease,  particularly  endocarditis,  which  are  probably  due 
to  embolism;  ulcers  from  arsenical,  phosphorus  and  especially  mer- 
curial poisoning,  the  last  of  which  occurs  from  the  long  continued  use 
of  medicinal  doses,  situated  in  the  colon  and  produced  by  the  elimina- 
tion of  the  metal;  finally,  we  have  ulcers  from  amyloid  disease,  per- 
nicious anemia,  and  leukemia,  and,  of  course,  from  any  neoplasm  of 
the  intestine,  particularly  in  the  later  stages  of  its  existence.  In  all 
of  these,  however,  the  original  disease  so  overshadows  the  effects  of  the 
ulceration  that  the  latter  is  often  only  accidentally  discovered  from  the 
evidence  of  diarrhea,  which  is  not  always  constant,  or  from  blood  in 
the  stool,  either  grossly  (tarry  stools)  or  by  chemical  tests.  The  fact 
is  that  ulcers  of  this  character  have  no  clinical  history  at  all,  and  a 
diagnosis  is  difficult.  It  is  markedly  different  with  another  group  of 
ulcers,  which  are  not  an  accidental  accompaniment  of  another  disease, 

480 


ULCERATIVE  PROCESSES   OF    THE  INTESTINE   AND   THEIR   SEQUELS       481 

but  have  an  entity  of  their  own.     Among  the  best  known  of  these  are 
the  duodenal  and  tubercular  ulcers. 


DUODENAL  ULCER. 

Duodenal  ulcer  is  proving  much  more  common  than  was  supposed, 
since  operations  have  been  more  freely  performed  for  its  relief.  The 
old  statistics,  based  on  the  autopsy  records,  showing  its  presence  in 
0.3-0.4  per  cent  of  all  those  undergoing  a  postmortem,  have  been  em- 
phatically changed  by  records  of  the  surgeons,  who  have  found  the 
duodenal  twice  as  common  as  the  gastric  ulcer.  Another  reason  for  the 
discrepancy  between  the  records  of  the  pathologists  and  the  surgeons  is 
that  the  latter  have  an  opportunity  to  examine  the  site  of  the  scar 
during  or  soon  after  its  activity,  while  the  latter  examine  the  intestinal 
canal  of  one  dying  of  intercurrent  disease  long  after  the  occurrence  of 
active  symptoms,  when  the  scar  is  very  thin  and  barely  perceptible. 
All  agree,  however,  that  duodenal  ulcer  is  much  more  common  in  males 
and  in  those  well  advanced  in  adult  life.  There  is  no  question  that 
the  duodenal,  as  well  as  the  gastric,  ulcer  is  caused  by  digestion,  since 
it  is  always  found  in  that  portion  of  the  intestine  bathed  by  the  acid 
gastric  juice.  Ulcers  below  the  entrance  of  the  common  duct  are  a 
rarity.  This  ulcer,  too,  is  often  a  complication  of  other  diseases,  par- 
ticularly those  which  impede  circulation — arteriosclerosis,  nephritis, 
and  septic  processes — through  thrombosis  or  embolism,  while  Boas  is 
convinced  that  the  abuse  of  alcohol  plays  an  important  part  in  its  pro- 
duction. To  burns  of  the  body  a  much  greater  role  has  been  assigned 
than  is  justifiable,  for  Rosenbach,  in  130  autopsies  of  those  dying  from 
burns,  could  only  find  one  unquestioned  ulcer  of  this  character  from 
that  cause.  The  position  of  the  ulcer  is  usually  directly  beyond  the 
sphincter  in  the  great  majority  of  cases;  in  fact,  so  closely  are  many 
duodenal  and  gastric  ulcers  united,  both  in  position  and  causation,  that 
many  prudent  diognosticians  designate  them  by  the  two  terms  united 
by  a  hyphen,  leaving  it  to  the  surgeon  to  establish  their  site ;  others  are 
not  more  than  3  cm.  from  the  sphincter  and  practically  never  beyond 
this. 

Symptoms. — The  symptoms  may  be  so  marked  that  a  diagnosis,  at 
least  of  gastroduodenal  ulcer,  is  easy,  but  in  many  instances  the  symp- 
toms, apart  from  indigestion,  weakness,  and  pallor,  are  so  vague  that  a 
copious  hemorrhage  is  our  first  warning  of  its  existence.  The  accident 
rooms  of  our  hospitals  have  a  considerable  number  of  such  cases,  where 
the  patient  is  never  conscious  of  being  ill  until  the  accident  happens. 


482  DISEASES   OF   THE   DIGESTIVE   TRACT 

No  case  of  unexplained  pallor  should  be  passed  over  lightly,  but  the 
meat-free  feces  must  always  be  examined  for  chemical  blood,  whose 
presence  may  be  the  first  distinctive  sign.  In  frank  cases,  pain  and  its 
peculiarities  may  of  themselves  establish  a  diagnosis.  It  comes  on 
suddenly  in  the  upper  abdomen,  to  the  right  of  the  median  line,  when 
the  patient  is  apparently  in  the  best  of  health ;  there  may  be  vomiting 
of  a  small  amount  of  sour-tasting  fluid.  This  pain  ordinarily  lasts 
from  two  to  three  hours  for  several  days  in  succession  and  then  disap- 
pears for  a  time,  during  which  the  sufferer  eats  what  he  chooses  with- 
out discomfort,  but  it  invariably  reappears.  Those  attacks  cpme  with 
such  regularity  and  disappear  so  quickly  that  one  is  almost  inclined  to 
regard  them  as  the  crises  of  tabes.  Such  attacks  should  never  be 
passed  over  without  examination  of  the  stool  for  blood,  which  will  usu- 
ally be  found ;  in  fact,  these  are  the  forms  which,  as  stated,  are  often 
brought  to  the  hospitals  in  a  state  of  collapse  from  a  terrific  hemor- 
rhage. These  attacks  may,  perhaps,  be  called  recurrent  or  periodic, 
but  we  also  have  a  form  which  is  more  chronic  and  which  stays  with 
the  patient  until  permanent  relief  from  gastroenterostomy  is  acquired. 
Here  the  patient  complains  constantly  of  pain  in  the  upper  abdomen, 
under  the  xiphoid  or  in  the  right  loin,  two  to  four  hours  after  eating. 
The  time  varies  markedly,  but  is  usually  constant  for  the  same  indi- 
vidual and  kind  of  food.  When  liquid  food  is  taken,  the  pain  appears 
earlier  than  when  solid.  The  pain  does  not  depend  on  the  character  of 
the  food  beyond  the  time  of  its  occurrence,  as  in  gastric  ulcer,  where 
liquid  food  may  cause  no  pain  whatever.  Directly  after  eating,  the  pain 
is  much  relieved  and  may  completely  disappear  for  the  time  being; 
hence  Moynihan's  term,  "hunger  pain."  As  the  patient  is  usually  in 
the  possession  of  an  unimpaired  appetite,  he  hastens,  as  soon  as  the 
pain  occurs,  to  partake  of  some  solid  or  liquid  food  for  relief.  Two 
explanations  have  been  offered  for  this  relief  by  food — one,  that  its 
introduction  causes,  for  a  time,  a  spasm  of  the'  pylorus  and  prevents 
the  acid  gastric  contents  from  irritating  the  ulcer,  and,  another,  that 
the  acid  of  the  gastric  contents  is  diminished  thereby.  The  x-ray  ex- 
amination, however,  shows  that  the  food  begins  to  enter  the  duodenum 
promptly,  and  pain  occurs  only  at  the  end  of  gastric  digestion ;  when 
the  stomach  is  absolutely  empty,  the  pain  ceases.  The  ' '  hunger  pains ' ' 
and  sour  eructations  at  the  end  of  digestion  are  not  unlike  similar 
symptoms  in  hypersecretion,  except  that  in  duodenal  ulcer  the  gastric 
contents  may  sometimes  show  no  increase  in  acidity ;  in  fact,  a  lessened 
one.  This  is  a  somewhat  suggestive  condition  in  diagnosing  duodenal 
ulcer — subjective  signs  of  hypersecretion  without  any  increase  of  such 


ULCERATIVE   PROCESSES   OF    THE   INTESTINE   AND   THEIR   SEQUELS       483 

secretion.  Here,  too,  are  remissions  of  symptoms  for  months,  only  to 
recur  with  their  former  severity.  While  many  claim  to  make  a  diag- 
nosis from  symptoms  alone,  still  the  objective  examination  of  patient 
and  feces  is  necessary  to  insure  us  from  mistake.  One  of  the  most 
constant  observations  made  is  that  the  feces  contain  chemical  blood. 
This  may  not  be  detected  the  first  time,  but  a  subsequent  examination 


Fig.  82.- 


-Radiogram  of  duodenal  ulcer.      Outline  defect  at  A  shown  by  arrow. 
Dr.  Arial  W.  George.) 


(Collection  of 


vsdll  probably  show  it.  Profuse  hemorrhage,  with  tarry  stools,  is  only 
a  complication,  and  we  should  discover  the  blood  long  before  this 
occurs.  Unfortunately,  cases  have  been  known  where  no  blood  could 
be  discovered,  but  a  week  or  two  later  excessive  hemorrhage  took  place. 
Therefore,  if  no  blood  is  present,  we  cannot  absolutely  exclude  duodenal 


484  DISEASES  OF   THE   DIGESTIVE   TRACT 

ulcer.  A  second  most  reliable  sign  is  a  distinct  tenderness  on  the  right 
side  of  the  abdomen,  above  the  navel,  in  the  parasternal  line.  In  some 
cases  this  occurs  only  during  the  prevalence  of  the  pain,  and  may  be 
accompanied  by  rigidity  or  spasm  of  the  right  rectus.  Furthermore, 
there  is  always  a  point  which  is  tender  to  pressure  in  the  back,  to  the 
right  of  the  last  dorsal  and  first  lumbar  vertebra,  while  in  a  few  in- 
stances a  light  blow  upon  the  spinous  processes  of  the  third  and  fourth 
dorsal  may  be  found  painful.  The  examination  of  the  gastric  con- 
tents shows  relatively  increased  acidity  in  comparatively  few  instances, 
but  digestive  hypersecretion  or  continuous  secretion  from  its  irritation 
are  not  uncommon.  The  x-ray  examination  is  of  the  greatest  aid  in 
establishing  a  diagnosis. 

A  study  of  these  radiograms  shows  a  rapid  early  emptying  of  the 
stomach,  the  duodenum  drawn  markedly  to  the  right  and  apparently 
fixed  when  adhesions  have  occurred,  a  marked  filling  of  the  first  part 
of  the  duodenum,  and,  later,  a  cessation  of  gastric  movements,  so  that 
long  after  the  stomach  should  be  emptied  (six  hours)  there  is  still  a 
distinct  residue  in  that  organ.  Furthermore,  it  is  not  unusual,  after 
the  stomach  is  empty,  to  find  a  small  residue  of  bismuth  attached  to 
the  duodenal  wall,  above  which-  a  small  air  bubble  may  sometimes  be 
seen.  To  summarize,  then,  there  a:re-the  concealed  cases  of  duodenal 
ulcers,  marked  by  anemia  and  increasing  weakness,  those  accompanied 
by  duodenal  crisis,  and,  last,  those  associated  with  "hunger  pain," 
which  come  and  go  with  various  lengths  of  remissions,  \nth  chemical 
blood  in  the  feces  and  well-marked  tender  points  front  and  back,  as 
well  as  occasional  hypersecretion  of  the  stomach.       -"'-..     / 

Complications. — The  complications  accompanying  the  chronic  form 
so  obscure  the  original  disease  that  they  offer  the  greatest  difficulty  in 
diagnosis.  By  adhesions  of  the  duodenum  to  the  liver  or  gallbladder, 
the  common  or  hepatic  duct  may  be  so  twisted  that  bile  may  be  found 
in  the  urine,  and  typical  gallstone  colics  may  occur,  when  at  operation 
the  gallbladder  may  be  found  free  from  stones  or  cholelithiasis.  An 
adhesion  to  the  head  of  the  pancreas,  too,  by  causing  a  kink  in  Wir- 
sung's  duct,  may  produce  abundant  neutral  fat  and  muscle  fibers  in 
the  stool  when  the  pancreas  itself  is  free  from  disease.  Bands,  also, 
may  form  which,  by  kinking  or  moderately  constricting  the  duodenum, 
cause  constant  vomiting,  which  leads  one  to  think  of  gastric  ulcer.  In 
such  a  case  under  our  observation,  confirmed  by  operation,  the  vomitus 
was  also  deeply  stained  with  bile.  These  complications,  perhaps,  de- 
mand oftener  the  aid  of  a  surgeon  than  the  original  disease  itself. 

Treatment. — The  treatment  must  necessarilv  be  the  same  as  that  of 


ULCERATIVE  PROCESSES  OF.  THE  INTESTINE   AND   THEIR   SEQUELiE       485 

gastric  ulcer,  described  on  page  311 — rest  in  bed,  liquid  diet,  etc. — ^until 
the  period  when  we  feel  assured  that  internal  therapy  will  be  of  no 
avail.  This  point  has  been  reached  when,  in  spite  of  treatment,  several 
periods  of  pain,  with  intervals  of  freedom,  have  been  passed,  or  when 
the  feces  show  continually  traces  of  "occult"  blood,  indicating  that  the 
ulcer  has  not  healed,  when  we  must  summon  the  surgeon  to  our  aid. 
In  a  gastric  ulcer  where  the  patient  has  reached  a  point  when  coarse 
food  can  be  taken  without  discomfort,  we  may  well  suppose  that  the 
ulcer  has  healed,  but  this  is  not  so  in  a  duodenal  ulcer,  where  the  char- 
acter of  the  food  plays  no  part  at  all,  nor  can  the  absence  of  blood  in 
the  feces  prove  absolutely  that  the  ulcer  has  cicatrized.  A  long  con- 
tinuance of  freedom  from  pain  after  medicinal  treatment  will  show 
the  probability  of  permanent  cicatrization  of  the  ulcer.  To  this  end, 
bismuth  undoubtedly  aids,  which,  as  subnitrate,  subcarbonate,  or  sub- 
gallate,  may  be  given  in  doses  of  0.5  gram  (7 14  grains)  three  or  four 
times  daily.  Furthermore,  on  account  of  the  frequency  of  recurrence, 
the  patient,  after  an  ostensible  cure,  must  be  warned  against  any  excess 
in  diet  (condiments,  highly  seasoned  food,  etc.)  or  the  use  of  alcohol, 
and  advised  to  report  to  some  physician  twice  a  year  for  examination. 

INTESTINAL  TUBERCULOSIS. 

Intestinal  tuberculosis,  next  to  typhoid  and  dysentery,  is  the  most 
common  cause  of  ulcerations  of  the  intestine.  As  a  complication  of 
pulmonary  tuberculosis,  produced  by  swallowing  the  sputum,  it  is  very 
common,  being  found  at  autopsy  in  50-60  per  cent  of  all  cases.  The 
primary  form,  or  that  resulting  from  infection  from  food  or  other  sub- 
stances entering  the  digestive  tract,  is  extremely  rare,  and  is  found 
chiefly  in  children.  From  the  pathological  institute  at  Kiel  the  figures 
are  28  instances  of  primary  intestinal  tuberculosis  out  of  600  autopsies, 
while  those  from  Breslau  are  13,  of  whom  8  were  children,  in  1,100 
autopsies.  Although  the  discussion  has  been  long  and  bitter,  there  is 
but  little  question  that  the  milk  of  tubercular  cows  may  produce  this 
form  of  tuberculosis,  as  well  as  butter  and  cheese  made  from  the 
product  of  those  cows,  and  the  meat  of  tubercular  animals. 

The  pathology  of  these  ulcers  is  dependent  on  the  fact  that  the  bacilli 
become  entangled  in  the  follicles  of  the  intestine,  various  follicles 
unite,  and  finally  the  process  breaks  through  the  mucous  membrane, 
and  we  have  the  full-fledged  ulcer.  These  exist  chiefly  in  the  lower 
ileum  and  the  colon,  may  remain  simple  ulcers,  or  by  granulation  tissue 
produce  tumors,  particularly  at  the  ileocecal  valve,  or  may  extend  until 


486  DISEASES   OF   THE   DIGESTIVE   TRACT 

they  become  annular  and  then  produce  stenosis.  The  rectum  is  also 
a  favorite  site,  afid  many  a  fistula  about  the  anus  is  of  tubercular 
origin.  Less  often,  and  only  once  in  our  experience,  has  a  tumor  of 
tubercular  nature  been  found  at  the  sigmoid,  similar  in  every  way  to 
those  found  at  the  cecum.  Peritoneal  effusion  often  accompanies,  and 
an  ulcer  may  break  into  the  peritoneal  cavity,  with  the  result  of  fatal 
peritonitis. 

Symptoms. — The  symptoms,  of  course,  are  largely  diarrhea  and 
emaciation,  but  the  former  does  not  necessarily  occur,  nor  should  we 
regard  every  victim  of  pulmonary  tuberculosis  as  the  possessor  of  in- 
testinal ulcers  because  he  has  diarrhea.  Unless  there  is  a  stricture, 
there  is  no  pain  preceding  or  accompanying  the  stools,  nor  is  there 
intestinal  rigidity  or  gurgling.  The  stools  number  from  four  to  eight 
daily,  and  are  dependent  not  so  much  on  the  number  of  ulcers,  which 
may  be  confined  to  one,  as  to  the  normal  or  abnormal  condition  of  the 
remaining  mucous  membrane.  These  movements  bear  no  relation  to 
the  kind  of  food,  though  many  a  patient  will  mention  certain  articles 
as  productive  of  diarrhea.  The  feces  are  liquid,  of  a  dark  color,  alka- 
line reaction,  with  all  the  food  remnants  present,  without  preponder- 
ance of  any  one,  and  fine  shreds  of  mucus  from  the  small  intestine, 
distinguished  by  the  adherence  of  partially  digested  epithelial  cells, 
with  nuclei  intact,  and  numerous  individual  nuclei  are  present. 

The  tubercle  bacilli,  of  course,  occur ;  but,  if  pulmonary  tuberculosis 
also  exists,  the  presumption  is  that  they  come  from  the  swallowed 
sputum,  unless  found  in  or  attached  to  these  masses  of  mucus,  which 
should  always  be  properly  stained  when  the  bacilli  are  suspected,  and, 
when  found  in  such  fragments,  these  bacilli  can  be  utilized  to 
their  fullest  extent  in  favor  of  intestinal  tuberculosis.  Blood  is  rarely 
present  in  more  than  the  merest  traces,  to  be  detected  by  chemical 
means  (Weber),  and  a  profuse  hemorrhage  would  exclude  a  tubercular 
process  on  account  of  the  slow  and  gradual  onset  of  the  latter.  Pus 
is  never  found  except  in  the  tuberculous  fistulae  already  mentioned. 
When  pain  is  present,  it  is  not  colicky,  but  steady,  and  not  severe. 
Palpation  can  sometimes  elicit  slight  tenderness,  but  the  parts  of  the 
intestine  cannot  be  mapped  out,  showing  that  they  are  flaccid,  nor  is 
there  any  spasm  of  the  superficial  muscles.  In  fact,  in  a  case  recently 
under  our  observation  the  woman,  though  suffering  from  pulmonary 
and  intestinal,  as  well  as  peritoneal  tuberculosis,  complained  more  of 
the  small  amount  of  fluid  in  the  abdomen  than  from  the  other  con- 
ditions. There  is  sometimes  moderate  distention  of  the  abdomen,  such 
as  one  would  find  in  typhoid. 


ULCERATIVE  PROCESSES   OF    THE  INTESTINE   AND   THEIR   SEQUELAE       487 

The  general  condition  always  suffers  severely.  The  constant  dis- 
turbance of  sleep  by  the  diarrhea,  the  fear  of  the  patient  that  eating 
increases  it,  and  oftener  the  lack  of  appetite,  soon  bring  the  victim  into 
a  state  of  extreme  emaciation;  in  fact,  a  mere  skeleton.  Of  course  a 
part  of  this  is  due  to  the  accompanying  phthisical  process,  but  primary 
cases  show  the  same  changes.  A  rise  of  temperature,  with  erratic 
changes  known  as  pyemic,  with  nightly  sweats,  also  accompanies  the 
primary  as  well  as  the  secondary  form,  showing  the  absorption  of  pus- 
producing  bacteria  into  the  blood.  A  marked  anemia,  often  of  the 
type  of  pernicious,  is  associated  with  the  disease,  and  persists  even 
after  recovery  of  the  local  condition  by  cicatrization.  The  course  of 
the  disease  is  steady,  and  it  terminates  usually  in  death  after  the 
diarrhea  has  become  well  established. 

The  complications  are  most  often  the  extension  to  the  peritoneum, 
with  exudation  and  infection  of  the  glands.  Rupture  and  fatal  peri- 
tonitis may  happen,  but  are  rare.  The  strictures  resulting  from  these 
ulcers  may  produce  sudden  occlusion  or  ileus  when  their  presence  was 
not  suspected,  though  a  part  of  this  stenosis  may  be  due  to  spasm. 
Stenoses  from  this  cause  are  more  apt  to  be  multiple,  which  increases 
the  difficulty  of  diagnosis. 

The  ileocecal  tumor,  found  usually  during  the  period  between  20  and 
30  years,  begins  very  gradually,  with  loss  of  flesh,  pallor,  failing  appe- 
tite, and  diarrhea  alternating  with  confinement  of  the  bowels.  Soon 
there  is  a  sense  of  weight  and  discomfort  in  the  right  lower  abdomen, 
increasing  to  pain  as  soon  as  signs  of  stenosis  appear,  as  they  undoubt- 
edly will.  Then  the  middle  of  the  abdomen  is  found  somewhat  dis- 
tended, and  the  alternating  rigidity  and  relaxation  of  the  small  in- 
testine indicate  promptly  where  the  obstruction  lies — at  the  ileocecal 
valve.  At  this  time,  too,  if  not  before,  at  the  same  site  a  tumor-like 
body  can  be  felt,  immovable,  either  smooth  or  sometimes  nodular,  gen- 
erally painless,  and  with  its  length  exceeding  its  breadth.  Fever  may 
or  may  not  accompany,  but  with  all  tubercular  involvement  of  the  in- 
testine increased  urine  indican  is  common.  After  this  period  is 
reached  there  is  marked  constipation.  The  feces  show  nothing  char- 
acteristic except  the  patches  of  mucus,  in  which,  as  well  as  in  other 
tuberculous  processes,  the  peculiar  bacilli  may  be  found.  The  detec- 
tion of  the  ordinary  tuberculous  ulcer  is  not  so  difficult  to  establish  be- 
cause it  occurs  chiefly  in  sufferers  from  phthisis,  and  the  detection  of 
the  bacilli  in  the  mucous  shreds  is  not  difficult,  but  the  mere  presence  of 
diarrhea  must  not  be  accepted  as  a  proof,  in  these  days  of  forced  feed- 
ing of  the  tuberculous,  when  an  ileocolic  catarrh  may  be  set  up.     The 


4:88  DISEASES   OF    THE   DIGESTIVE   TRACT 

cecal  tumor,  however,  presents  the  greatest  difficulty  of  diagnosis  on 
account  of  its  similarity  to  malignant  disease  and  perityphlitis.  Usu- 
ally the  age  of  the  patient  fixes  it  as  a  benign  growth,  but  this  is  not 
absolute,  and,  when  the  pulmonary  condition  is  so  advanced  that  it  can 
be  readily  detected,  there  can  be  no  doubt.  Then,  again,  the  presence 
of;  rise  of  temperature  or  the  bizarre  character  of  the  same  would  favor 
a  benign  tumor. 

Treatment. — The  treatment  is  both  preventive  and  curative.  The 
former  consists  of  a  careful  inspection  of  the  cows,  as  is  now  carried 
out  by  the  Government,  with  occasional  testing  with  tuberculin,  so  that 
children,  who  are  the  greatest  sufferers  from  the  primary  form,  may 
be  protected  in  their  food — milk.  Sterilization  of  the  milk  is  also  a 
safeguard,  which  must  not  be  neglected.  Sufferers  from  phthisis  must 
be  especially  warned  never  to  swallow  sputum,  which  is  accomplished 
by  the  sanitaria  in  giving  patients  boxes  for  the  deposition  of  the 
sputum.  As  to  the  various  means  suggested  for  exciting  gastric  juice 
to  destroy  the  bacteria,  should  they  reach  the  stomach,  they  seem  to  us 
like  erecting  a  house  of  cards.  It  is  much  better  to  endeavor  to  keep 
the  sputum  out  of  the  digestive  tract.  When  the  tuberculous  process  is 
actually  established  in  the  intestine,  a  diet  such  as  recommended  under 
Enterocolitis  (page  439)  may  be  tried,  as  the  associated  catarrh  is 
largely  the  cause  of  the  diarrhea,  but  milk  and  milk  products  are  badly 
borne,  and  one  is  soon  compelled  to  leave  the  patient  to  his  own  choice 
of  food,  when,  strange  to  say,  the  movements  are  sometimes  diminished 
in  number.  It  is  needless  to  state  that  salads  should  be  avoided,  as 
well  as  vegetables  rich  in  cellulose,  and  that  an  occasional  resort  to 
clear  soups,  broths,  gruels,  gelatine,  custards,  and  well-boiled  rice  may 
be  necessary  for  a  few  days;  but,  if  this  does  not  immediately  check 
the  diarrhea,  it  is  doing  harm  rather  than  good,  for  the  maintenance 
of  nutrition  is  an  absolute  need,  and,  as  can  be  readily  recognized,  these 
articles  are  lacking  in  food  calories  on  account  of  their  volume.  Rectal 
injections  of  egg,  milk,  and  a  predigested  carbohydrate  food  do  not, 
of  course,  help  in  checking  the  frequent  stools,  but  once  a  day,  at  bed- 
time, given  with  10  drops  of  laudanum,  it  does  assist  in  staying  the 
rapid  loss  of  flesh,  and  has  never  increased  the  irritability  of  the  in- 
testine in  our  hands.  The  usual  astringents — tannalbin  and  tannigen, 
bismuth  subsalicylate  and  subgallate,  as  well  as  calcium  carbonate  or 
phosphate — will  help  for  a  time,  but  eventually  we  have  to  fly  to  the 
use  of  opium,  either  as  suppositories  of  the  extract,  in  doses  of  0.02 
gram  (%  grain),  or  the  deodorized  tincture,  in  doses  of  5-10  drops, 
two  or  three  times  daily.     We  begin,  of  course,  with  the  smaller  dose 


ULCERATIVE  PROCESSES   OF   THE  INTESTINE   AND   THEIR   SEQUEL.^]       489 

and  gradually  increase  as  the  occasion  demands,  but  it  is  astonishing 
what  large  doses  may  be  given  without  apparent  harm  to  the  patient. 
Colon  washings  with  starch  or  gum  arabic  solutions,  containing  medica- 
ments— dermatol,  tannin,  etc. — never  appealed  to  us  because  no  ease 
under  our  observation  was  ever  benefited  by  them.  Surgical  inter- 
vention can  aid  only  in  overcoming  the  stenosis  and  in  such  a  way  has 
been  very  beneficial;  the  attempt  to  remove  an  active  ulcer  fails  to 
relieve  the  condition,  because  they  are  usually  multiple,  and  it  often 
spreads  the  disease  to  the  neighboring  areas ;  when,  however,  the  ulcer 
has  healed,  then  it  is  a  different  matter,  and  the  excision  of  this  portion 
of  the  intestine  can  be  heartily  recommended  for,  if  the  scar  is  at  all 
extensive,  constriction  is  sure  to  follow,  and  an  early  operation  may 
prevent  a  fatal  ileus  when  the  chances  of  recovery  from  the  operation 
are  vastly  lessened.  The  ileocecal  granulation  tumor  should  be  re- 
moved as  early  as  detected,  for  nothing  is  surer  than  that  an  obstruction 
will  eventually  occur.  The  rectal  ulcers  can  be  treated  for  a  time  with 
powders  through  the  speculum  or  rectoscope,  but  as  soon  as  they  form 
fistulfB,  the  latter  should  be  opened  freely  and  curetted,  an  operation, 
sad  to  say,  which  may  have  to  be  done  repeatedly,  for  they  recur  with 
astonishing  frequency. 


CHAPTER  XVIII 

DISEASES  OF  THE  INTESTINAL  AND  MESENTERIC  BLOOD 

VESSELS 

VENOUS  HYPEREMIA. 

Venous  hyperemia  of  the  intestine  is  dependent  on  direct  obstruction 
to  the  return  flow  of  the  blood  to  the  heart,  as  in  hepatic  cirrhosis,  or 
to  a  failure  of  the  heart  to  sustain  the  blood  pressure,  as  in  mitral 
insufficiency.  Extensive  emphysema,  too,  may  produce  a  backing  up 
of  the  blood  in  the  abdominal  veins,  and  another  most  marked  cause  is 
paralysis  of  any  portion  of  the  intestine.  At  an  autopsy  it  is  not  al- 
ways possible  to  detect  this  hyperemia,  for  the  blood  is  forced  out  of 
the  veins  by  the  contraction  and  rigidity  of  the  smooth  muscles.  When 
persistent,  however,  the  mucous  membrane  is  bluish-red,  distinctly 
edematous  and  thickened.  This  state  does  not  necessarily  involve  the 
whole  tract,  only  portions  of  it,  but,  wherever  it  does  occur,  the  dilated 
veins  will  be  found  as  well  in  the  submucous  as  in  the  serous  layers. 
Varices  of  the  distended  veins  are  extremely  rare.  In  the  stomach 
we  recognize  the  fact  that  this  stagnation  of  blood  is  the  cause  of  ca- 
tarrh, but  in  the  intestine  it  is  not  so  clear,  though  it  may  be. 

Symptoms. — The  symptoms,  which  are  not  always  in  evidence,  con- 
sist chiefly  of  the  accumulation  of  gas  in  the  intestine  to  such  an  ex- 
tent that  the  abdomen  is  visibly  distended,  and  the  pressure  against  the 
diaphragm  holding  it  in  a  higher  position  than  formerly  checks  the 
free  movements  of  the  heart  and  lungs,  which  add  to  the  difficulty  of 
maintaining  the  circulation.  It  has,  furthermore,  been  demonstrated 
that  the  cause  of  this  is  not  an  increased  generation  of  gas,  but  a  faulty 
absorption.  In  addition,  there  is  always  a  moderate  amount  of  in- 
testinal sluggishness,  which  is  unaccountable,  since  ordinarily  a  faulty 
aeration  of  the  blood  produces  diarrhea.  Utilization  of  the  food  is  un- 
impaired in  mild  cases,  but,  when  severe,  fat  has  been  found  in  the 
feces  and  sometimes  meat  fibers.  These  events  may  arise  from  the 
catarrh,  which  may  spring  up  from  the  passive  hyperemia,  causing 
diarrhea,  with  much  mucus.  These  attacks  are  not  of  long  duration, 
but  extensive  enough  to  relieve  temporarily  the  preceding  constipation. 

490 


DISEASES   OF    THE   INTESTINAL  AND   MESENTERIC   BLOOD   VESSELS       491 

Hemorrhage  from  the  dilated  vessels  is  not  common,  though  it  has 
been  found  severe  enough  to  cause  death,  where  autopsy  showed  no 
thrombus  or  embolus.  Varices  are  common  in  the  mucous  membrane 
when  there  is  no  obstruction  in  the  portal  circulation,  and  from  these 
fatal  hemorrhages  may  occur. 

HEMORRHOIDS. 

Hemorrhoids  (piles)  are,  primarily,  only  dilated  veins,  found  about 
the  anus,  which  sometimes  bleed,  but  cause  little  other  disturbance,  and 
should  be  distinguished  from  the  inflamed  thrombosed  hemorrhoidal 
veins  which  may  arise  from  them.  The  former  are  very  common;  in 
fact,  it  is  said  that  one-third  of  all  adults,  with  predominance  of  the 
male  sex,  possess  them.  Children  are  rarely  afflicted,  but  sometimes  an 
instance  is  found.  The  sphincter  divides  these  into  external,  which 
can  be  readily  seen,  and  internal,  which  can  be  observed  only  through  a 
speculum,  though  they  can  often  be  felt.  The  internal  ones  are  al- 
ways in  close  vicinity  of  the  sphincter,  and  never  cover  the  circum- 
ference of  the  rectum,  but  are  apt  to  be  grouped  on  one  side  as  bluish- 
red  slight  eminences,  and,  if  true  varices,  are  soft  and  not  unlike  those 
dilated  veins  found  in  the  leg  or  the  scrotum,  so  that,  unless  inflamed, 
we  cannot  speak  of  them  as  nodules.  Often  thrombi  form  in  them, 
and  more  or  less  interstitial  tissue  is  produced  by  inflammation,  when 
they  appear  as  hardened,  somewhat  tender,  nodules,  which  can  be 
readily  distinguished  by  sight  or  touch  from  the  surrounding  tissue. 
As  to  causation,  our  views  are  changing,  and  we  no  longer  hold 
cirrhosis  of  the  liver  or  cardiac  insufficiency  as  responsible  for  more 
than  a  minute  portion  of  them ;  in  fact,  the  former  are  of tener  only 
an  accompaniment.  The  true  obstruction  is  more  local,  as  in  preg- 
nancy, during  which  at  least  one-third  of  all  women  acquire  hemor- 
rhoids, which  may  disappear  or  persist  after  its  termination.  Next 
to  this  cause,  constipation  probably  produces  more  examples  than  any 
other,  but  we  must  differentiate  between  that  form  with  rectum  packed 
with  feces,  where  pressure  plays  a  part,  and  that  variety  where  the 
delay  is  higher  up  and  the  terminal  of  the  great  intestine  is  always 
found  empty.  In  the  latter,  straining  at  stool  is  unquestionably  the 
chief  factor,  acting  on  weakened  veins.  Among  the  lesser  causes  are 
enlarged  prostate  in  men,  retroverted  uterus  in  women,  tumors  of  the 
rectum  or  ovaries,  or  inflammatory  attacks  of  these  parts,  and  occasion- 
ally cystitis.  Rarely  do  hemorrhoids  exist  for  any  length  of  time 
without  becoming  inflamed  from  thrombus  formation,  the  cause  of 


492  DISEASES   OF   THE   DIGESTIVE   TRACT 

which  is  the  entrance  of  microorganisms  from  the  fecal  matter,  the  use 
■of  improper  closet  paper,  and  the  onset  of  eczema  with  scratching. 
"Whatever  the  cause  may  be,  a  small  painful  nodule  is  formed,  which 
after  a  time  subsides,  leaving  a  pendulous  mass  of  connective  tissue, 
sometimes  termed  a  "tab."  When  this  is  outside  the  sphincter,  it 
causes  no  further  difficulty,  but,  if  inside,  it  is  often  the  starting  point 
of  a  polypus,  which  at  removal  often  requires  a  microscopic  examina- 
tion to  determine  whether  it  is  malignant ;  pedunculated  at  first,  it  may 
become  adherent  to  the  interior  of  the  intestine  almost  throughout  its 
whole  length. 

Symptoms. — The  symptoms  of  the  uncomplicated  hemorrhoids  are 
often  so  insignificant  that  the  patient's  attention  is  first  called  to 
them  by  the  presence  of  blood  in  the  stool.  Still,  in  an  earlier  period 
there  may  be  itching  and  burning  about  the  anus,  usually  associated 
with  constipation,  to  which  may  be  attributed  usually  the  sense  of  full- 
ness in  the  anal  region,  the  confusion  of  the  thoughts,  and  the  inability 
to  apply  oneself  to  mental  efforts.  The  bleeding  at  first  is  only 
minimal — a  smear  on  the  closet  paper  and  only  at  stool;  later  it  be- 
comes more  excessive,  and  may  be  found  on  coughing  or  sneezing, 
and  exaggerated  after  intemperate  eating  or  drinking  of  alcoholic 
leverages  or  after  a  long  railroad  journey.  The  blood  is  always 
smeared  over  the  stool,  if  formed — never  mixed  with  it.  If  small  fecal 
particles  are  present  (colon  spasm),  they  may  be  found  swimming  in  a 
small  pool  of  blood.  The  blood  is  usually  pure,  bright-red  or  dark- 
red,  never  brown  (hematin),  and  is  unmixed  with  products  of  inflam- 
m.ation  (mucus  and  pus)  unless  a  proctitis  is  associated.  Occasionally 
the  patient,  if  full-blooded,  feels  relief  after  a  discharge  of  blood  with 
the  stool,  but  oftener  the  sufferers  are  blanched  from  the  repeated  loss 
of  blood.  Invariably  with  the  history  of  bleeding  from  the  anus,  that 
region  must  be  inspected,  and  often  bluish  distended  veins  may  be 
seen,  interspersed  with  the  so-called  "tabs"  or  remnants  of  inflamma- 
tion of  the  hemorrhoids,  while  occasionally  these  can  be  seen  to  pro- 
trude through  the  anus,  particularly  when  the  patient  strains.  If  not 
seen  at  once,  the  rectoscope  should  be  used,  when  they  are  readily  dis- 
cerned within  the  sphincter. 

The  simple  inflammation  of  the  hemorrhoids  usually  affects  only  the 
■external  and  possibly  intermediate  veins.  The  patient  feels  a  sense 
of  heat  and  pressure  at  the  anus,  an  unusual  desire  for  defecation, 
and  pain  during  this  act.  The  patient  himself,  on  touching  the  part, 
discovers  a  small  tender  spot  and  makes  his  own  diagnosis.  The  phy- 
sician finds  at  this  time  slight  hardening  and  some  tenderness  over 


DISEASES   OF   THE   INTESTINAL  AND   MESENTERIC   BLOOD   VESSELS       495 

the  vein,  but  this  is  not  the  true  nodule  of  thrombus  formation ;  this 
milder  form  may  disappear  and  recur  several  times.  When,  however,, 
thrombi  form,  accompanied  by  phlebitis,  then  the  attack  is  more  severe, 
and  a  nodule  is  formed  which  is  extremely  painful,  so  that  the  passage 
of  feces  or  flatus  causes  exquisite  torture.  The  patient  is  conscious  of 
a  foreign  body  in  the  anal  region,  which  he  tries  to  remove  by  strain- 
ing at  stool,  and  the  desire  for  defecation  is  constant;  there  is  also- 
throbbing  of  the  parts.  Sitting  is  painful,  strangury  is  sometimes, 
present,  and  there  may  be  a  slight  rise  in  temperature.  This  condition 
may  continue  a  week,  and  after  it  has  passed  away  there  is  only  an 
empty  sack  left  to  show  its  site.  A  still  more  serious  complication  is- 
the  protrusion  of  the  hemorrhoids  through  the  anus  at  defecation,  or 
often  by  sneezing  or  coughing.  For  a  time  these  can  be  replaced,  but. 
there  comes  a  period  when  their  base  is  so  compressed  by  the  cramp  of 
the  sphincter  that  strangulation  takes  place.  These  strangulated 
hemorrhoids  become  very  edematous,  the  dark-red  color  changes  to  an 
ashen  hue,  they  discharge  a  blood-stained  fluid,  and  there  may  be  com- 
plete gangrene.  Often,  however,  the  thrombus  organizes,  leaving  the 
''tab"  of  connective  tissue.  These  strangulated  piles  increase  all  the 
difficulties  spoken  of  before,  and,  if  suppuration  follows,  we  may  have 
a  decided  rise  of  temperature,  and,  unless  opened,  the  pus  may  burrow 
into  the  perirectal  tissue  and  form  an  abscess  which  usually  breaks  out- 
ward. These  attacks  of  inflammation  are  soon  over,  but  others  occur 
unless  the  patient  is  exceedingly  careful  (cleanliness  of  parts  and  regu- 
lated movements),  and  a  real  hemorrhoidal  status  is  set  up  in  certain 
individuals.  When  once  inflamed,  however,  that  hemorrhoid  ''ceases- 
from  troubling"  and  the  hemorrhage  always  comes  from  the  unin- 
flamed  varices.  The  excrescences,  remnants  of  former  hemorrhoids,, 
do  no  harm  except  to  retain  fragments  of  feces  and  thereby  incite  in- 
fection in  fresh  varices.  Finally,  after  years  of  progressive  activity 
and  quiescence,  when  the  anus  is  surrounded  by  a  rosette  of  hemor- 
rhoidal remnants,  the  process  may  cease  and  no  more  discomfort  be 
suffered. 

The  differentiation  of  these  hemorrhoids  from  polypi  and  condylo- 
mata is  not  difficult  when  exterior;  when  intermediate,  they  can  be 
forced  out  of  the  anus  usually  by  bearing  down,  particularly  after  an 
enema.  From  beginning  rectal  carcinoma  in  the  elderly  the  distinction 
is  not  so  easy,  and  one  should  never  be  satisfied  without  an  examina- 
tion with  the  use  of  the  rectoscope. 

Treatment. — The  treatment  of  hemorrhoids  should  comprise,  firsts 
the  removal  of  the  most  frequent  cause,  constipation,  by  the  diet  given 


494  DISEASES   OF   THE   DIGESTIVE   TRACT 

on  page  416,  Furthermore,  all  condiments  and  alcohol  should  be  for- 
bidden, and  the  patient  should  be  warned  against  too  vigorous  bearing 
down  at  stool.  Strong  purgatives  must  not  be  employed,  but  an  ex- 
cellent remedy  is  the  old  sulphur  and  cream  of  tartar  mixture,  which 
can  be  improvised  as  follows: 

^     Sulphuris  loti 6.0  or  I14  drams 

Potassii  bitratratis     20.0  or  %  ounce 

M.     Fac  in  chartulas  vel  tablettas  XX. 
Sig. :     Two  or  three  at  bedtime. 

When  these  fail,  we  may  use  pulvis  glycerrhizae  composi'tus,  fluid- 
extractum  rhamni  purshianae,  or  tamarinden. 

The  use  of  enemata  should  be  forbidden,  particularly  with  hard 
rubber  tips,  though  the  soft  rubber  rectal  tube,  well  lubricated  and  skill- 
fully introduced,  never  seems  to  do  any  harm.  On  account  of  the  pos- 
sibility, too,  of  irritation,  glycerine  injections  or  suppositories  must 
never  be  employed.  When  the  hemorrhoids  are  prolapsed,  long  rail- 
road journeys  and  horseback  and  bicycle  riding  should  be  forbidden. 
After  the  act  of  defecation,  the  anus  should  be  cleaned  with  the  softest 
of  closet  paper,  dipped  in  4  per  cent  boracic  acid  solution,  and  after  it 
is  dried  the  piles  should  be  well  smeared  with  olive  oil,  and  an  effort 
made  to  push  them  through  the  anal  ring  with  a  small  wedge  of  ab- 
sorbent cotton  if  they  have  become  protruded  during  defecation. 

The  complications  demand  their  appropriate  means  of  treatment. 
Irritation,  as  manifested  by  stinging  and  smarting,  can  be  controlled 
by  a  suppository  containing  anesthesin  0.2  gram  (3  grains). 
Chrysarobin,  in  conjunction  with  iodoform,  may  be  used  in  a  supposi- 
tory, as  follows : 

IJ     lodoformi    0.6  or  10  grains 

Chrysarobini 1.2  or  20  grains 

Extracti   belladonnae 0.4  or  6  grains 

Olei  theobromatis q.s. 

M.     Fac  suppositaria  rectalia  XX. 

Sig.:     Insert  one  at  bedtime. 

For  the  clinic,  where  the  cost  of  suppositories  is  objectionable,  we 
may  employ  the  following  salve,  which  should  be  smeared  on  small 
pledgets  of  absorbent  cotton  and  inserted  into  the  anus  after  the  stool 
and  preliminary  cleansing  process : 

IJ     Pulveris  gallse, 
Pulveris  opii, 
Plumbi  acetatis,  aa 1.0  or  15  grains 


DISEASES   OF    THE   INTESTINAL   AND   MESENTERIC   BLOOD   VESSELS       495 

Lanolini, 

Petrolati,  aa  15.0  or  %  ounce 

M.  Sig. :     Smear  on  cotton  and  insert  after  cleansing  parts. 

Bleeding  sometimes  demands  the  most  energetic  treatment,  par- 
ticularly when  the  patient  begins  to  be  blanched.  Small  injections  of 
ice  water  through  a  double-current  catheter  are  often  sufficient,  while 
internally  one  gives  the  following: 

3J     Fluidextracti  hamamelidis  foliorum, 

Fluidextracti  Hydrastis,  aa   30.0  or  1  ounce 

M.  Sig.:     Teaspoonful  in  water  three  times  daily. 

Boas  recommends  the  introduction  of  20  c.c.  of  10  per  cent  watery 
solution  of  calcium  chloride,  with  a  soft  rubber  bulb  syringe,  after  the 
stool.  Adrenalin  suppositories  may  also  succeed  in  checking  the  bleed- 
ing.    When  the  oozing  does  not  cease  from  these  means,  it  is  wiser  to 


Fig.  83. — Rectal  pessary. 

introduce  a  rectoscope  or  speculum  and  pack  firmly  with  iodoform 
gauze,  or  cauterize  the  bleeding  varix. 

When  the  hemorrhoids  become  inflamed,  it  is  absolutely  necessary 
to  place  the  patient  in  bed,  with  the  foot  raised,  and  a  suppository  of 
extractum  opii  or  extractum  belladonnae  should  be  introduced,  or  a  com- 
bination of  both,  while  ice  should  be  applied  to  the  affected  part. 
When  the  ice  is  badly  borne,  we  may  employ  poultices  of  cataplasma 
kaolini,  N.  F.  When  the  inflamed  hemorrhoids  show  a  tendency  to 
suppuration,  local  anesthesia  should  be  produced  by  cocaine  or  quinine 
and  urea,  the  nodule  laid  open,  the  clot  removed,  and  a  stitch  inserted ; 
in  two  days  the  patient  can  get  out  of  bed,  on  the  fourth  a  laxative  may 
be  taken,  and  on  the  sixth  the  stitch  removed  (Zweig).  When  the 
hemorrhoids  are  protruded  through  the  anus  and  only  moderately 
edematous  and  inflamed,  an  attempt  should  be  made  with  the  finger, 
armed  with  a  rubber  cot  and  well  oiled,  to  restore  them,  which  can  be 
aided  by  first  painting  them  with  a  5  per  cent  cocaine  solution.     No 


496  DISEASES   OP    THE   DIGESTIVE   TRACT 

unnecessary  force  should  be  used,  and  it  may  take  fifteen  minutes  of 
the  most  careful  effort,  much  as  one  proceeds  with  an  incarcerated 
hernia,  before  success  crowns  our  efforts ;  if,  at  last,  they  are  returned^ 
a  pledget  of  cotton  should  be  introduced  and  a  T-bandage  applied,  or  a 
rectal  pessary  may  be  used.  The  latter  is  much  more  effective,  but  the 
patient  complains  often  of  discomfort  from  its  presence.  When,  how- 
ever, the  strangulation  has  proceeded  to  the  point  of  beginning  gan- 
grene, no  further  efforts  at  reposition  should  be  made,  and  we  can  only 
assume  an  expectant  attitude,  with  morphine  suppositories  to  control 
the  pain,  and  wait  for  the  time  of  demarcation  and  sloughing  of  the 
necrosed  portion. 

In  resume  we  may  say  that  three  conditions  arise  when  surgical  in- 
tervention is  necessary:  (1)  when  repeated  bleeding  causes  anemia, 
(2)  when  there  is  constant  protrusion  of  the  internal  variety  through 
the  anus,  (3)  where  the  varices  become  repeatedly  inflamed.  Two 
methods  of  surgical  procedure  have  been  described  under  Proctitis, 
page  479 — The  one,  actual  cauterj^,  requiring  all  the  paraphernalia  of 
an  operating  room,  wkh  the  use  of  ether ;  the  other,  phenol-glycerine 
injection,  performed  by  the  physician  in  his  office.  A  third  method, 
now  less  popular,  is  ligature  at  the  base  of  the  nodules,  which  appears 
the  least  commendable  of  a%  though  imitating  nature's  method  of  cure, 
when  strangulation  has  som^mes  been  accompanied  by  tetanus. 

ARTERIOSCLEROSIS. 

Arteriosclerosis  of  the  intestinal  arteries  is  a  disease  which  attacks 
chiefly  those  beyond  50  years  of  age,  and  more  males  than  females, 
though  Buch  reports  cases  as  young  as  26  and  29  years  of  age  when 
the  process  was  of  syphilitic  origin.  Besides  lues,  which  plays  the  most 
important  part  in  causation,  alcohol,  plumbism,  and  the  excessive  use 
of  tobacco  have  been  accused.  The  vessel  most  often  attacked  is  the 
abdominal  aorta,  which  may  be  broadened  or  lengthened  and  made 
more  movable,  or  it  may  assume  a  new  position.  This  hardening  of  the 
abdominal  aorta  may  exist  apart  from  that  of  the  thoracic  aorta  or  of 
the  mesenteric  arteries.  When,  however,  the  latter  are  sclerosed,  the 
abdominal  aorta  usually  participates.  While  this  process  produces 
enlargement  of  the  aorta,  the  mesenteric  arteries  are  narrowed,  par-, 
ticularly  where  they  leave  the  former.  A  part  of  the  symptoms  is 
due  to  spasm  of  the  arteries,  for  Pal  saw  the  blood  pressure  rise 
from  its  usual  90-100  mm.  to  170-220  mm.  during  an  attack  and  as 
rapidly  diminish  to  its  former  height  afterward.     It  can  be  readily 


DISEASES   OF    THE   INTESTINAL   AND   MESENTERIC   BLOOD   VESSELS       497 

seen  that  these  sclerosed  portions  in  the  narrowed  mesenteric  arteries 
furnish  the  most  favorable  conditions  for  the  formation  of  thrombi 
(damaged  intima  and  slowing  of  the  blood  current).  Buch  recognizes 
three  forms — one,  idiopathic,  or  at  least  existing  alone ;  another,  asso- 
ciated with  contracted  kidney;  and  the  third,  in  conjunction  with 
thoracic  aortitis  and  true  angina  pectoris. 

Symptoms. — The  symptoms  are  fairly  regular  in  their  nature,  and 
consist  of  attacks  of  abdominal  pain,  paroxysmal  in  character,  located 
usually  above  the  navel  in  the  median  line  and  extending  upward 
toward  the  costal  borders.  The  pain  may  be  either  burning  or  stab- 
bing, or,  as  some  say,  indescribable.  The  duration  is  from  a  few 
minutes  to  half  an  hour,  and  its  greatest  peculiarity  is  its  frequency, 
occurring  often  several  times  a  day,  but  not  at  all  constant.  Food 
has  nothing  to  do  with  the  onset  of  the  attack,  but  it  is  brought  on 
by  exercise,  particularly  raising  a  heavy  object  from  the  ground  or 
ascending  stairs.  A  horizontal  position  may  cause  the  onset  in  some, 
while  in  others  the  emotions  (anger)  are  held  responsible.  Cardiac 
asthma  and  cyanosis  rarely  accompany  the  epigastric  pain.  Other 
signs  of  arteriosclerosis  may  be  found  in  the  rigid  radials  and 
temporals  and  a  hypertrophied  heart  but  lack  of  compensation  of  the 
last  is  never  present.  As  a  result,  too,  the  second  aortic  sound  is 
found  accentuated. 

Physical  examination  may  not  always  show  an  enlarged  or  mov- 
able abdominal  aorta,  but  it  is  always  tender,  and  this  tenderness  may 
be  elicited  by  pressing  on  either  side  of  the  aorta  or  over  the  vertebrae. 
This  pressure  point  is  also  situated  exactly  where  the  spontaneous 
pain  arises.  As  can  be  readily  seen,  the  attacks  are  very  similar, 
except  in  the  location  of  the  pain,  to  those  of  angina  pectoris,  from 
which  it  is  often  difificult  to  disassociate  them,  and,  in  fact,  with 
which  they  may  exist  in  unison.  The  digestive  tract  is  rarely  in- 
volved, yet  there  may  be  vomiting  with  the  pain,  and  the  patients 
are  usually  mildly  constipated.  When  there  is  a  conjoint  arterio- 
sclerosis of  the  brain,  we  may  have  giddiness,  headache,  and  failing 
memory,  which  will  aid  in  the  explanation  of  the  abdominal  pain. 
Hemorrhages,  too,  may  occur,  as  evinced  by  tarry  stools;  in  fact,  are 
claimed  by  some  to  precede  the  onset  of  the  disease. 

Diagnosis. — When  severe  pain  in  elderly  people  occurs  spasmodi- 
cally, we  must  think,  of  course,  of  malignant  disease,  but  those  who 
suffer  from  abdominal  aortitis  are  often  in  the  best  of  physical  con- 
dition, with  ruddy  cheeks,  and,  apart  from  an  occasional  gaseous 
distention  of  certain  parts  of  the  intestinal  tract  during  the  pain. 


498  DISEASES   OF   THE   DIGESTIVE   TRACT 

show  no  signs  of  stenosis.  True,  the  visible  pulsating  aorta  may  be 
due  to  a  growth  lying  over  it,  but  in  that  ease  the  aorta  cannot  be 
freely  palpated  and  its  anomalies  of  position  and  size  detected  as 
it  can  be  in  aortitis.  With  gastralgia  (ulcer?)  and  pseudoangina 
these  attacks  have  much  similarity,  but  the  former  come  in  younger 
individuals,  possibly  in  women  during  the  climacteric,  while  these 
occur  almost  invariably  in  elderly  men.  The  few  exceptions  where 
young  adults  are  affected  show  such  marked  manifestations  of  general 
arteriosclerosis  from  syphilis  (contracted  kidney,  hj'pertrophied  heart, 
etc.)  that  mistake  is  impossible.  The  onset  of  pain,  too,  in  pseudo- 
angina  usually  occurs  after  a  meal,  induced  perhaps  by  rapid  eating, 
awakens  the  patient  from  a  sound  sleep,  or  occurs  in  the  early 
morning,  but  never  after  violent  exercise,  which  is  peculiar  to  ab- 
dominal angina  as  well  as,  of  course,  to  the  thoracic  form.  Further- 
more, the  beneficial  effect  of  diuretin  and  strophanthus  confirms  the 
diagnosis. 

Treatment. — The  treatment  consists,  first,  in  placing  the  patient  in 
bed.  If  the  attacks  are  frequent  and  if  the  full  prone  position 
aggravates  them,  as  sometimes  happens,  the  bed  may  be  made  up  in  a 
jNIorris  chair,  or  a  head-rest  may  be  placed  in  the  bed,  so  that  the 
sufferer  will  be  half  seated.  The  application  of  the  electric  pad  or 
thermophore  to  the  abdomen  stills  the  pain  and  helps  to  prevent  re- 
currence. Where  the  patient  is  obese  and  the  heart  and  aorta  are 
sound,  moderate  exercise  in  a  gymnasium  will  often  prevent  the  return 
of  the  pain.  In  conjunction  with  the  gymnastics,  abdominal  massage 
should  be  employed,  which  has  been  proven  to  relieve  the  increased 
blood  pressure,  and  therefore  allows  less  incitement  for  a  spasm  of  the 
abdominal  aorta.  The  diet  seems  to  be  unimportant  in  controlling 
the  attacks,  but  alcohol  and  more  than  the  most  moderate  use  of  tobacco 
should  be  forbidden. 

jMedicinal  treatment  is  confined  to  a  few  drugs,  of  which  diuretin 
(theobromin-sodium  salicylate)  may  be  given  in  doses  of  0.5  gram 
(8  grains)  three  or  four  times  daily,  well  crushed,  if  in  tablet  form, 
before  swallowed,  or  in  the  following  form : 

Ti.     Diuretini    6.0  or  1  %  drams 

Aquse   destillatse    50.0  or  1%  ounces 

Aquae  menthae  piperitse,  q.s.  ad 240.0  or  8  ounces 

M.  Sig. :     Tablespoonful  three  times  daily. 

The  most  remarkable  relief  from  pain  which  comes  after  the  use 
of  diuretin  can  be  accomplished  only  by  its  checking  arteriospasm. 
Tinctura  strophanthi  also  has  the  same  favorable  influence  as  a  pre- 


DISEASES   OF    THE   INTESTINAL   AND   MESENTERIC   BLOOD   VESSELS        499 

ventive  of  spasm,  and  should  be  used  in  doses  of  4^8  drops  three 
times  daily,  beginning  with  the  smaller  amount  and  increasing  accord- 
ing to  the  needs  of  the  patient.  Iodine  also  has  proved  its  worth  in 
checking  attacks  of  pain  and  lowering  blood  pressure.  Whether  we 
use  the  sodium  or  potassium  iodide  in  half-gram  doses  three  times  daily, 
or  the  newer  and,  of  course,  more  expensive  sajodin,  in  similar  doses, 
supplied  in  tubes  of  twenty,  is  indifferent  except  to  the  palate  and  the 
purse,  for  the  latter  is  undoubtedly  more  easily  taken  and  less  liable 
to  produce  iodism.  The  acute  attack  itself  is  of  so  short  duration  that 
the  physician  can  rarely  reach  his  patient  before  it  is  over,  but,  if  he 
does  arrive,  an  injection  of  morphine  is  practically  the  only  thing  which 
will  check  the  spasm.  If  much  weakness  of  the  heart  be  present  and 
the  subsequent  depressing  effect  of  morphine  on  that  organ  be  feared, 
a  second  injection  of  camphor  may  be  given,  for  which  purpose  manu- 
facturers provide  very  convenient  ampules  containing  one  dose.  The 
tablets  of  glonoin  (nitroglycerin),  containing  0.0006  (^oo  grain),  or 
pearls  of  amyl  nitrite,  0.3  gram  (5  minims),  may  be  left  with  the  pa- 
tient to  be  taken,  or  the  latter  crushed  and  inhaled  at  the  beginning  of 
the  attack,  but  they  are  not  nearly  as  effective  as  in  angina  pectoris. 

EMBOLISM  AND  THROMBOSIS. 

Embolism  and  thrombosis  of  the  mesenteric  arteries  are  not  common 
occurrences,  but,  when  they  do  take  place,  cause  the  greatest  difficulty 
in  diagnosis  unless  their  possible  advent  is  recognized.  The  most  com- 
mon causes  of  embolism  and  the  more  frequent  thrombosis  are  endo- 
carditis, an  atheromatous  aorta,  or  the  formation  of  a  clot  in  the  pul- 
monary veins.  Both  mesenteries  may  be  occluded  by  a  clot  at  the 
same  time,  but  a  search  through  the  literature  shows  that  the  superior 
is  more  commonly  affected.  If  the  clot  is  large  and  lodges  near  the 
aorta,  the  entire  portion  supplied  with  blood  will  be  affected ;  if  in  the 
superior,  the  horizontal  portion  of  the  duodenum,  the  rest  of  the  small 
intestine,  the  cecum,  and  the  ascending  and  transverse  colon  may  be 
involved  in  the  cutting  off  of  the  supply  of  blood ;  if  in  the  inferior 
mesenteric,  the  descending  colon  and  sigmoid  will  be  deprived  of  their 
blood  supply.  The  results  are  either  a  bloody  infarct  of  this  portion 
or  portions  of  the  intestine  if  there  is  some  return  of  blood  through  the 
veins — i.e.,  the  occlusion  is  not  complete — or  anemic  infarct  and  gan- 
grene when  there  is  no  return  flow — i.e.,  if  it  is  complete.  The  latter 
may  sometimes  take  place  when  the  veins  are  likewise  blocked  by 
thrombi.     This  has  been  experimentally  demonstrated   on   dogs,   in 


500  DISEASES   OF   THE   DIGESTIVE   TRACT 

which,  when  complete  closure  of  the  mesentery  is  produced,  anemic 
infarct  occurs,  and,  when  incomplete,  hemorrhagic.  Sievers  reports 
the  autopsy  of  a  woman  of  56  years  who  lived  twenty-nine  hours  after 
the  accident,  at  which  an  embolus  6  cm.  long  was  found  in  the  superior 
mesenteric,  only  a  short  distance  from  the  aorta,  and  from  1  meter 
below  the  pylorus  to  7  cm.  below  the  ileocecal  valve  the  intestine  was 
found  red,  swollen,  and  filled  with  brownish-red  semifluid  contents ; 
the  duodenum,  upper  part  of  the  jejunum,  and  descending  colon  were 
perfectly  normal.  The  intestine  does  not  necessarily  become  gan- 
grenous from  either  the  hemorrhagic  or  the  anemic  infarct,  and,  after 
circulation  is  restored,  may  emerge  unharmed,  as  pathologists  have 
shown  us.  Usually,  however,  that  portion  of  the  intestine  suffers 
more  or  less  damage.  If  the  emboli  are  smaller,  they  may  occlude 
the  smaller  divisions  of  the  mesentery,  producing  localized  infarcts, 
as  in  a  case  of  ours,  where  at  autopsy  about  30  cm.  of  ileum  were  found 
of  a  burgundy  wine  color  and  extremely  thickened,  and  one  reported  by 
Lambert,  where  several  feet  of  the  small  intestines  were  thus  affected 
by  multiple  emboli  in  the  smaller  mesenteric  arteries.  When  circula- 
tion is  restored  in  such  circumscribed  portions  of  the  intestine,  heal- 
ing may  take  place  with  the  formation  of  a  stricture,  or,  if  the  emboli 
reach  the  capillaries,  ulcers  may  result.  When  thrombosis  takes  place, 
it  is  due  to  arteriosclerotic  changes  in  the  arteries  as  a  result  of  syphilis  ; 
if  the  occlusion  is  complete,  the  same  changes  occur  in  the  intestine  as 
in  embolism,  but,  as  the  obstruction  is  gradual,  the  changes  take  place 
more  slowly  and  the  symptoms  of  abdominal  angina  precede.  Throm- 
bosis of  the  veins  is  much  more  common  than  of  the  arteries,  and  pro- 
ceeds from  the  portal  vein,  due  oftenest  to  empyema  of  the  gallbladder 
or  from  infection  arising  in  the  intestine  and  taken  up  by  the  smaller 
veins.  The  result  on  the  intestine  (hemorrhagic  infarct)  is  the  same 
as  in  partial  occlusion  of  the  artery. 

Symptoms. — The  symptoms  always  come  suddenly,  usually  without 
any  warning.  In  our  own  case  they  followed  some  weeks  after  an 
attack  of  cholelithiasis  in  a  woman  of  60,  and  began  in  the  night  with 
such  severity  that  an  ileus  was  diagnosed.  Rarely  there  may  be  pro- 
dromal symptoms  for  weeks  or  even  months  where  a  thrombus  forms, 
consisting  chiefly  of  abdominal  pain.  Two  types  of  the  disease  are 
generally  recognized,  though  they  may  be  similar  in  certain  features. 
Both  forms  are  noted  for  severe  sudden  abdominal  pain,  which  is 
first  localized  in  the  epigastrium,  but  finally  streams  over  the  whole 
abdomen,  accompanied  by  vomiting,  cool  extremities,  small  rapid  pulse, 
and  subnormal  temperature,  accepted  by  all  as  indicating  shock.     The 


DISEASES   OF   THE   INTESTINAL.  AND   MESENTERIC   BLOOD   VESSELS        501 

only  departure  from  this  picture  is  the  occasional  absence  of  severe 
pain.  From  this  point,  however,  the  ways  separate.  The  first  type 
is  accompanied  by  abundant  tarry  stools,  or,  as  Lohr  reports,  by  hema- 
temesis;  usually  one  bloody  stool  is  passed,  but  often  a  veritable  di- 
arrhea follows,  with  copious  blood.  After  this  the  pain  subsides  some- 
what until  the  abdomen  begins  to  distend,  and  we  have  diffused  ten- 
derness and  rigidity — in  short,  the  evidences  of  a  peritonitis.  The 
other  form  has  all  the  distinguishing  marks  of  an  ileus  and  is  usually 
mistaken  for  it;  the  pain  is  continuous,  the  state  of  collapse  is  more 
marked,  and  no  passage  of  stool  or  gas  takes  place.  At  first  there  is 
subnormal  temperature,  and  later  there  may  be  a  slight  rise ;  vomiting 
may  continue  until  finally  it  is  of  a  fecal  character,  as  in  Lambert's 
case.  There  is  moderately  diffused  distention  and  abdominal  tender- 
ness, but  no  movement  of  the  intestine  can  be  seen  or  felt  (absence  of 
rigidity),  nor  is  gurgling  heard,  as  in  true  stenosis.  If  the  patient 
survive  the  original  shock,  peritoneal  involvement  may  arise  later. 
There  is  not  the  slightest  question  that  complete  paralysis  of  the  sec- 
tion of  the  intestine  involved  takes  place.  Death,  if  operation  is  not 
performed  at  once,  occurs  early ;  in  Siever  's  case  in  twenty-nine  hours ; 
in  our  own,  death  occurred  at  the  end  of  twelve  days,  during  which 
period  there  was  almost  constant  vomiting  and  no  stool  passed,  but 
the  peritoneum  was  not  involved  at  autopsy — only  a  partial  or  gradu- 
ally increasing  occlusion  can  account  for  this.  The  difficulty  of  diag- 
nosis is  shown  when  we  learn  that,  out  of  96  cases  reported  by  New- 
malin,  only  18  were  diagnosed  during  life;  in  fact,  where  no  hem- 
orrhage occurs,  it  is  practically  impossible  to  distinguish  this  condition 
from  ileus  caused  by  other  agencies. 

Treatment. — The  treatment  is  only  surgical,  and  the  removal  of  the 
inf arcted  portion  of  the  intestine  should  be  performed  just  as  early  as 
possible  and  before  the  peritoneal  complication  takes  place.  It  is  not 
necessary  to  wait  for  an  absolute  diagnosis,  either  tarry  stools  or  evi- 
dences of  acute  ileus  are  present,  and  an  exploratory  operation  should 
take  place  at  once.  The  early  removal  of  the  paralyzed  portion  of  the 
intestine  has  been  successfully  performed  several  times,  and  there  can 
be  no  argument  for  delay  in  such  a  fatal  disease  as  this.  AVhen  opera- 
tion is  refused  or  a  surgeon  is  not  available,  all  we  can  do  is  to  relieve 
the  pain  by  the  hypodermic  use  of  morphia,  and,  if  the  case  is  at  all 
prolonged,  feed  by  the  rectum  on  account  of  the  constant  vomiting. 


CHAPTER  XIX 

INTESTINAL  STENOSES  AND  OCCLUSIONS 

These  terms  strictly  mean  different  degrees  of  the  same  division,  the 
first  referring  to  a  partial  closure  of  the  lumen  of  the  intestine,  and 
the  latter  a  complete  one.  The  results,  too,  of  the  former  may  differ 
markedly,  whether  the  narrowing  is  in  the  small  intestine,  where  the 
liquid  fecal  contents  often  allow  a  long  period  to  elapse  without  sj'^mp- 
toms,  or  in  the  lower  part  of  the  large  intestine,  where  their  solid 
character  very  soon  produces  manifestations  in  the  form  of  alternating 
diarrhea  and  constipation,  colicky  attacks,  which  may  last  for  hours 
with  intermissions,  hut  with  steadily  increasing  difficulty  as  the  pas- 
sage becomes  narrower,  and  more  or  less  extensive  meteorism,  in  ac- 
cordance with  the  site  of  the  narrowing.  The  total  obstruction,  when 
neither  feces  nor  gas  can  pass,  may  be  gradual  or  sudden  as  in  intus- 
susception at  the  ileocecal  valve  or  twists  at  the  sigmoid.  In  the  latter 
case,  vomiting  is  persistent  until  it  becomes  fecal.  When  the  obstruc- 
tion is  of  slow  growth,  the  portion  of  the  intestine  before  it  becomes 
hypertrophied  in  its  efforts  to  force  the  contents  forward,  and  also 
in  time  becomes  dilated,  like  a  heart  when  the  process  of  hypertrophy 
has  reached  its  limit  and  the  obstruction  remains  the  same ;  soon,  also, 
there  is  an  enteritis  set  up  by  the  fermentation  or  putrefaction  of  the 
stagnating  contents,  whether  in  the  small  or  large  intestine,  in  that 
part  lying  before  the  stenosis;  minute  ulcers,  too,  are  not  uncommon 
in  this  area,  supposed  to  be  due  to  the  toxins  produced  by  bacteria. 

STENOSES. 

The  causes  of  these  strictures  are  scars  from  ulcerative  colitis,  tuber- 
culosis, typhoid,  the  results  of  inflammation  after  reposition  of  in- 
carcerated hernige,  bands  produced  by  localized  peritonitis  (in  one 
instance  in  our  experience  extending  from  the  cecum  to  the  sigmoid), 
malignant  new  growth  and  pressure  from  adjacent  tumors  (as  in  one 
case  seen  by  us),  malignant  disease  of  the  uterus,  which  compressed 
the  sigmoid  without  its  being  involved  in  the  process. 

Symptoms. — The  symptoms  rarely  follow  a  well-defined  course.     In 

502 


INTESTINAL.   STENOSES   AND   OCCLUSIONS  503 

some  patients  change  in  the  regularity  and  consistence  of  the  stools, 
where  previously  the  function  has  been  as  systematic  as  the  interchange 
of  day  and  night,  is  most  prominent;  in  some,  spasmodic  pains,  and 
in  others  the  meteorism.  "When  we  consider  that  the  intestine,  with  its 
enormous  length  and  constantly  changing  content,  offers  four  to  five 
favorite  sites  for  narrowing,  such  variations  could  only  be  expected. 
One  fact  is  true,  however — wherever  the  stenosis  may  be  situated,  the 
symptoms  are  progressive  in  severity,  though,  as  stated,  narrowing  may 
exist  in  the  small  intestine  a  long  time  before  symptoms  are  distinctive. 
As  to  the  movements,  when  the  site  is  in  the  small  intestine,  constipa- 
tion does  not  occur;  the  stools  are  liquid,  of  very  offensive  odor,  and 
contain  much  mucus,  while  they  may  be  mixed  with  blood  and  pus, 
which  does  not  necessarily  indicate  destruction  of  tissue.  When  the 
narrowing  is  at  the  ileocecal  valve  or  anywhere  between  that  point  and 
the  hepatic  flexure,  we  have  the  same  tendency  to  occasional  attacks  of 
diarrhea,  but  rarely  constipation  unless  that  had  existed  for  many 
years.  On  the  contrary,  when  the  stenosis  is  between  the  hepatic 
flexure  and  the  terminus  of  the  tract,  restricted  movements  are  the 
rule,  but  a  woman  under  our  observation,  on  whom  a  resection  of  the 
descending  colon  for  an  annular  carcinoma  at  the  level  of  the  crest  of 
the  ilium  was  performed,  had  numerous  loose  stools,  which  were  some- 
times mixed  with  blood.  ]\Iore  attention  should  be  paid  to  the  quantity 
than  the  frequency  of  the  movements,  for  often  the  desire  is  constantly 
present,  and  the  patient  goes  frequently  to  stool,  but  passes  only  a 
trifle.  A  peculiarity  of  the  feces,  which  undoubtedly  enables  them  to 
pass  the  narroAved  portion  of  the  canal,  is  the  ability  of  the  scybala  to 
induce  transudation  from  the  mucous  membrane  and  become  softened 
on  the  outside  as  well  as  covered  with  mucus.  The  peculiar  shapes — 
ribbon,  lead  pencil,  etc. — have  no  significance  as  a  mark  of  permanent 
stenosis,  since  they  can  be  produced  equally  as  well  by  spasm.  Briefly, 
then,  narrowing  in  the  small  intestine  causes  occasional  diarrhea  in 
conjunction  with  normal  stool.  Narrowing  in  the  caliber  of  the  large 
intestine  is  accompanied  by  constipation,  with  occasional  periodic  at- 
tacks of  frequent,  scanty  discharges  of  foul-smelling,  liquid  fecal  mat- 
ter. The  pain  shows  many  characteristic  features.  It  may  have  no 
relation  to  food,  or  may  come  quite  regularly  three  to  four  hours 
after  it  is  taken,  and  is  aggravated  by  food  containing  much  cellulose, 
like  lettuce,  cabbage,  coarse  bread,  nuts,  etc.  It  begins  suddenly,  soon 
reaches  its  maximum,  during  which  the  patient  often  holds  his  breath 
and  presses  with  both  hands  over  its  site.  Cold  sweats  may  break  out 
on  his  brow,  and  in  a  quarter  to  a  half  minute  it  is  over,  accompanied 


504  DISEASES   OF   THE   DIGESTIVE   TRACT 

by  a  loud  gurgling  sound,  but  this  relief  is  only  momentary,  and  it 
returns  with  almost  the  regularity  of  labor  pains,  at  short  intervals, 
during  that  attack,  and  then,  exhausted,  the  sufferer  may  be  free  from 
discomfort  for  a  portion  of  the  day  and  perhaps  until  the  next  day, 
for  the  attacks  are  not  equally  distributed  over  the  twenty-four  hours. 
During  these  periods  of  pain  no  gas  or  feces  are  passed,  but  after  the 
painful  attack  they  are  passed  freely,  to  which  the  patient  always 
ascribes  his  relief.  Vomiting  may  occur  at  the  height  of  the  pain, 
but  it  is  purely  reflex  and  has  nothing  to  do  with  the  fecal  vomiting 
of  acute  complete  obstruction.  The  site  of  the  narrowing  can  be  easily 
ascertained  by  the  location  of  the  pain  in  its  less  acute  paroxysms,  for 
during  the  height  of  an  attack  it  streams  everywhere.  Vagaries  in 
this  respect  may  occur,  however,  for  in  an  elderly  man,  with  narrow- 
ing in  the  sigmoid — as  could  be  easily  seen  from  the  end  of  the  wave 
of  contraction  and  as  proven  by  operation — ^the  pain  was  always  re- 
ferred to,  in  his  words  as  in  the  "pit  of  the  stomach,"  Usually  the 
pain  is  severer  the  narrower  the  constriction  becomes  and  the  more 
vigorous  the  visible  peristalsis  (rigidity).  The  visible  and  palpable 
contractions  of  the  intestine  above  the  constriction  are  also  very  char- 
acteristic. As  the  patient  lies  in  bed,  the  abdomen  may  appear  per- 
fectly normal,  but  soon  in  some  portion  a  wave  begins,  by  which  a 
portion  of  the  gut  becomes  raised  and  visible,  much  as  a  fire  hose 
when  the  engine  is  started.  This  elevation  of  the  hypertrophied  por- 
tion of  the  gut,  particularly  in  thin-walled  individuals,  increases  until 
it  is  plainly  visible,  or  in  thick-walled  is  palpable  as  a  round  well-filled 
tube,  whose  distal  terminus  is  the  stenosed  portion.  Such  an  appear- 
ance may  be  simulated  by  lead  colic,  the  exaggerated  physiological  con- 
tractions (tormina  intestinorum),  or  by  the  spasm  of  membranous 
colitis,  but  in  all  these  cases  the  portion  before  the  constriction  is 
soft,  elastic,  or  filled  with  gas,  but  never  with  a  large  amount  of  fluid. 
At  the  close  of  the  rigidity,  and  just  before  the  complete  relaxation, 
one  can  always  hear  the  gurgling,  which  indicates  the  passage  of  fluid 
matter  and  gas  from  a  higher  well-filled  to  an  empty  lower  portion  of 
the  intestine,  but  not  necessarily  through  the  narrowed  contracted 
section,  for  the  sound  is  heard  above  this  point.  After  each  period 
of  rigidity  there  comes  a  desire  for  stool,  which  cannot  always  be  grati- 
fied. As  these  rigid  portions  occur  only  in  the  hypertrophied  section 
of  the  intestine,  much  can  be  learned  as  to  the  site  of  the  stricture 
after  they  become  well  established.  If  at  the  rectum,  the  sigmoid  will 
be  found  to  undergo  these  changes;  if  at  the  sigmoid,  the  descending 
colon  and  possibly  the  transverse  and  ascending,  so  that  a  horseshoe 


INTESTINAL   STENOSES   AND   OCCLUSIONS  505 

appearance  is  presented,  with  the  straight  portions  in  the  flanks. 
The  great  size,  apart  from  the  position,  excludes  confusion  with  the 
small  intestine.  When  the  constriction  is  at  the  ileocecal  valve,  the 
rigidity  occurs  in  the  middle  of  the  abdomen,  often  in  parallel  layers, 
which  never  takes  place  from  a  colon  narrowing  unless  there  is  an  in- 
sufficient valve.  Often  in  colon  constriction,  as  well  as  those  of  the 
duodenum  or  jejunum,  the  waves  imitate  closely  those  of  the  stomach, 
except  that  they  run  from  right  to  left,  while  those  of  the  stomach  pro- 
ceed from  left  to  right.  After  the  spasm  is  over,  there  still  remains  in 
the  hypertrophied  portion  of  the  intestine  before  the  stenosis  a  small 
accumulation  of  gas,  which  will  indicate  where  the  rigidity  occurred, 
but  oftener  the  coil  of  intestine  sinks  below  the  surface  of  the  abdomen 
until  the  next  contraction.  On  percussion,  these  inflated  coils  afford  a 
loud  tympanitic  note,  which  during  the  spasm  becomes  flat  because  the 
gas  is  largely  driven  out  of  this  portion  of  the  intestine;  if  deep 
(colon),  the  note  may  be  absolutely  flat  in  the  flanks  and  changes  with 
the  position  of  the  patient,  much  as  in  accumulation  of  fluid  in  the  ab- 
domen, but  we  always  have  the  spurting  and  gurgling  sounds  to  guide 
us.  The  latter  may  also  occur  before  rigidity  establishes  the  presence 
of  a  stenosis,  but  are  not  to  be  relied  on,  because  they  may  occur  in 
functional  spasmodic  contractions  of  the  intestine,  but  never  at  the 
same  point  for  any  length  of  time.  The  only  general  condition  com- 
mon to  chronic  stenosis  of  the  intestine  is  an  increasing  anemia  and 
emaciation,  which  is  probably  due  to  the  intestinal  catarrh  and  waste 
of  food  elements.  Indican  of  the  urine  is  rarely  affected  in  colon  con- 
strictions, but  is  markedly  increased  in  those  of  the  small  intestine. 

Clinical  Picture. — The  clinical  picture  changes  in  accordance  with 
the  site  of  the  obstruction  and  its  completeness.  If  the  duodenum 
above  the  papilla  of  Vater  is  constricted,  we  cannot  distinguish  the 
condition,  unless  the  x-ray  examination  aids  us,  from  ordinary  pyloric 
obstruction ;  if  below  this  point,  however,  while  we  have  the  same  symp- 
toms of  epigastric  pressure,  eructations,  and  vomiting,  the  vomitus, 
washings  of  the  fasting  stomach,  and  gastric  contents  after  the  test 
breakfast  all  contain  bile.  Furthermore,  the  results  of  the  examination 
of  gastric  contents  show  varying  conditions  as  to  acidity.  In  one  case 
of  ours,  with  the  constriction  below  the  papilla,  found  at  operation, 
they  changed  from  no  free  hydrochloric  at  one  time  to  acidities  of  25 
and  63  at  another;  there  was  moderate  stasis,  and  our  history  of  the 
above  case  mentions  the  finding  of  lactic  acid  and  thread  bacilli.  The 
bowels  are  usually  confined,  with  occasional  attacks  of  diarrhea ; 
the  urine  is  much  diminished  and  generally  contains  an  increased 


506  DISEASES   OF   THE   DIGESTIVE   TRACT 

amount  of  indican,  while  in  the  ease  quoted  there  was  always  a  dis- 
tinct trace  of  bile  pigment  as  well ;  the  stools  contain  ample  stercobilin 
until  the  stenosis  becomes  complete,  and  then  they  become  clayey. 

The  narrowing  of  the  jejunum  or  ileum,  even  at  the  ileocecal  valve, 
has  symptoms  much  alike — rigidity  and  prominence  at  about  or  above 
the  navel  in  the  center,  while  the  flanks  remain  flattened.  There  is 
often  a  long  latent  period  when  only  at  a  certain  point  or  points — if 
the  stenoses  are  multiple,  as  sometimes  happens — the  gushes  can  be 
heard  and  felt,  but  there  is  no  marked  pain  other  than  a  sense  of  dis- 
comfort, and  no  rigidity  occurs.  If  this  group  of  symptoms  is  ac- 
companied by  diarrhea,  with  more  or  less  mucus  and  increasing  anemia, 
the  constriction  of  some  part  of  the  small  intestine  is  probable,  w'hich 
often  surprises  us  with  a  sudden  attack  of  complete  obstruction,  ac- 
companied by  constant  vomiting  and  prompt  hydrobilirubin  reaction 
in  the  vomitus.  Then  the  meteorism  so  far  predominates  over  the 
rigidity  that  the  latter  is  not  noticeable. 

Stenosis  at  the  middle  of  the  transverse  colon  or  before  does  not 
cause  the  restricted  enlargement  of  the  right  flank,  which  would  be  ex- 
pected on  account  of  the  weakening  and  lack  of  resistance  of  the  ileo- 
cecal valve,  so  that  the  protrusion  extends  well  into  the  middle  of  the 
abdomen.  The  succussion  of  the  cecum  is  marked,  but  alone  cannot  be 
taken  as  diagnostic  of  stenosis,  for  in  typhlatony  slopping  can  be 
elicited,  where  there  is  no  possibility  of  organic  constriction.  The 
hepatic  flexure  never  becomes  sufficiently  distended  to  be  visible,  the 
movements  are  variable,  diarrhea  and  persistent  constipation  alter- 
nating, or  the  latter  may  prevail,  and  indican  is  usually  unaffected, 
though  it  may  be  markedly  diminished.  When  the  stricture  is  situated 
low  down  in  the  tract,  the  rigidity  may  affect  the  whole  colon,  the 
descending  portion  and  sigmoid,  or  the  sigmoid  alone,  when  there  are 
sharp  turns  between  that  and  the  ascending  colon.  Here,  too,  the  lax 
fixation  of  the  sigmoid  may  produce  many  mistakes  in  diagnosis.  The 
form  of  the  stools  may  be  ribbon-  or  lead-pencil-shape,  or  may  form 
the  usual  cylinder  below  the  narrowing.  If  the  stools  are  solid  before 
they  reach  the  constriction,  there  is  less  liability  that  marked  meteorism 
will  be  found,  because  gas  passes  better  under  such  conditions  than 
when  mixed  with  fluid  contents.     The  indican  is  unaffected. 

The  duration  will  depend  largely  on  the  extent  and  continuance  of 
the  hypertrophy  of  the  gut  above  the  narrowed  portion.  It  wall  per- 
sist much  longer  in  the  young  than  in  the  old,  but,  when  dilatation 
occurs,  then  the  symptoms  of  ileus  (complete  closure)  follow.  In  the 
small  intestine  repeated  attacks  of  ileus  may  occur  and  the  patient 


INTESTINAL  STENOSES  AND   OCCLUSIONS  507 

overcome  them  without  operation,  but  in  the  colon  this  is  rare.  In 
the  small  intestine,  too,  one  rarely  can  tell  whether  a  sudden  closure  of 
the  lumen  is  really  an  acute  affair  or  the  outcome  of  a  latent  chronie 
stenosis  brought  on  by  indigested  food,  associated  spasm,  or  sudden  in- 
crease of  the  narrowing,  caused  by  overdistention  of  the  intestine  with 
gas.  Restitution  to  normal  condition  is  one  of  the  rarities  of  medicine, 
and  the  narrowing  continues,  with  temporary  or  remittent  obstruction,, 
or,  as  stated,  pursues  a  latent  course  until  sudden  and  complete  occlu- 
sion occurs,  one  of  the  most  ominous  accidents  with  which  the  pro- 
fession has  to  deal. 

OCCLUSION. 

Here  there  is  a  vast  difference,  both  in  the  pathologic  conditions  and 
symptoms,  whether  the  obstruction  is  actually  acute  as  well  as  sudden, 
or  whether  it  is  the  outcome  of  a  long  continued  previous  narrowing^ 
of  the  intestine.  Furthermore,  if  the  blood  supply  is  wholly  or  par- 
tially shut  off,  a  new  feature,  strangulation,  is  introduced.  If  acute, 
the  intestine  above  the  obstruction  is  full  and  tense,  while  that  portion 
below  is  collapsed  and  empty.  If  the  obstruction  is  low  down  and  the 
ileocecal  valve  holds,  only  the  colon  is  involved;  if  not,  the  distention 
can  be  traced  beyond  the  valve;  if  the  obstruction  is  in  the  small 
intestine,  the  distended  coils  can  be  followed  to  the  stomach.  At 
autopsy  the  walls  of  the  canal  are  always  found  thinned  and  well  in- 
jected with  distended  arteries.  AVhen,  however,  the  total  obstruction 
follows  the  partial,  the  enlargement  of  the  intestine  is  much  greater, 
for  in  this  case  it  has  wholly  lost  its  contractility.  When  strangula- 
tion takes  place,  we  have  a  double  feature  presented — the  closure  of 
the  lumen  of  the  gut  and  restriction  of  the  blood  supply  by  pinching 
some  of  the  mesenteric  vessels,  either  arterial  or  venous,  the  result 
being  the  same ;  hence,  in  addition  to  the  dilatation  of  the  intestine 
above  the  constriction,  we  have  a  leakage  of  blood  into  the  lumen  of  the 
canal  and  true  hemorrhagic  infarct.  There  follows  soon  a  gangrenous 
condition  of  the  pinched  intestine,  beginning  at  the  point  of  greatest 
pressure,  allowing  bacteria  free  ingress  to  the  peritoneal  cavity,  and 
resulting  only  too  often,  unless  surgical  relief  is  secured  at  once,  in 
fatal  peritonitis.  As  soon  as  the  complete  closure  occurs,  peristalsis  in 
parts  below  the  point  ceases,  while  above  it  is  exaggerated,  so  that  fecal 
contents  from  distant  parts  are  hurried  to  the  constricted  section,  and 
there  is  also  above  an  excessive  intestinal  secretion,  both  of  which  ac- 
count for  the  large  amount  of  fluid.  When  strangulation  occurs,  gas 
absorption  is  very  much  impaired,  as  it  always  is  where  the  circulation 


508  DISEASES   OF   THE   DIGESTIVE   TRACT 

is  slowed,  fermentation  continues  rapidly,  and  the  meteorism  increases 
in  proportion.  How  much  of  this  is  due  to  excretion  of  carbon  dioxide 
from  the  blood,  if  any,  is  not  known.  The  causes,  apart  from  those 
mentioned  for  stenosis  situated  in  the  walls  or  outside,  may  be  inside, 
such  as  gallstones,  which  are  more  apt  to  obstruct  the  duodenum  and 
jejunum,  or  enteroliths,  huge  concretions  of  lime  or  magnesium,  with 
more  or  less  plant  residue,  whose  favorite  site  is  in  the  lower  colon. 

STRANGULATION. 

Strangulation  is  due  to  many  causes,  such  as  peritoneal  bands;  an 
orifice  produced  by  the  adhesion  of  the  tip  of  the  appendix  to  the  ab- 
dominal wall,  through  which  a  coil  of  the  intestine  slips  and  is 
pinched;  narrow  slits  from  peritoneal  adhesion  in  the  omentum  or 
mesentery,  which  arise  from  injury  or  laparotomy,  through  which  the 
same  occurrence  takes  place.  Here,  too,  are  found  the  various  herniae 
at  the  inguinal  and  femoral  canals,  through  the  diaphragm  as  well  as 
through  the  rectal  and  vaginal  wall. 

INVAGINATION. 

Invagination,  by  which  a  superior  portion  of  the  intestine  slips 
within  an  inferior  like  a  sheath,  is  usually  accompanied  by  moderate, 
if  not  complete,  strangulation,  as  evinced  by  the  rapid  onset  of  bloody 
discharges  soon  after  the  event  and  the  occasional  necroses  and  dis- 
charge per  anum  of  the  invaginated  portion.  In  this  form  the  occlu- 
sion may  not  be  complete,  but,  on  account  of  the  subsequent  edema, 
narrowing  of  the  lumen  is  more  marked,  and  from  the  pressure  on  the 
mesenteric  vessels  the  symptoms  simulate  those  of  occlusion  rather  than 
stenosis  in  their  suddenness  and  severity.  The  favorite  sites  are  the 
ileocecal  orifice  and  the  sigmoid.  The  former  is  most  common,  forming 
70  per  cent  in  children,  who  are  the  chief  sufferers  from  this  form  of 
obstruction,  under  1  year  of  age  and  at  least  half  of  those  over  1  year 
old  who  suffer  from  obstruction. 

Volvulus,  or  a  twist  of  a  portion  of  the  intestine,  together  with  its 
mesentery  on  its  axis,  which  usually  coincides  with  the  former,  also 
produces  all  the  symptoms  of  strangulation.  The  most  common  site  of 
this  is  in  the  sigmoid  and  cecum,  where  this  circular  motion  is  favored 
by  too  long  a  mesentery. 

Sjnnptoms. — The  symptoms  of  occlusion  and  strangulation  may  be 
considered  together  because  they  differ  only  in  degree. 


INTESTINAL   STENOSES   AND   OCCLUSIONS  509 

Occlusion  is  distinguished  by  complete  cessation  of  stool  and  passage 
of  gas — stoppage,  as  it  is  commonly  termed  among  the  laity — and  may 
be  sudden  or  gradual  in  its  onset.  The  fecal  fragments,  which  are 
sometimes  washed  out  by  enemata,  lead  to  our  self-deception,  for  they 
are  from  the  ampulla  as  well  as  the  air  which  escapes  after  the  injec- 
tion, as  it  is  probably  introduced  with  the  fluid.  The  colicky  attacks 
soon  follow,  and,  if  accompanied  by  powerful  peristalsis  with  rigidity 
we  may  conclude  it  is  not  an  absolutely  acute  affair,  but  has  been  pre- 
ceded by  partial  obstruction.  When,  on  the  contrary,  there  are  no 
energetic  contractions,  accompanied  by  hardening  of  the  section  of  in- 
testine above,  we  may  be  assured  that  the  obstruction  is  really  acute. 
Still,  in  individuals  with  thin  abdominal  walls  the  intestines  can  be  seen 
to  be  in  a  state  of  active  motion,  but  this  is  in  no  degree  comparable  to 
the  powerful  spasmodic  contraction  of  a  hypertrophied  section,  which 
can  be  seen  above  the  level  and  distinctly  felt.  These  tumultuous 
movements  of  the  intestine  in  absolutely  acute  cases  soon  cease,  as  it 
becomes  paralyzed  and  the  pain  subsides  with  them.  The  meteorism 
may  be  lacking  at  first,  since  the  blood  supply  is  not  impaired,  but 
later,  from  the  increasing  distention  of  the  portion  before  the  occlusion, 
absorption  of  the  gases  is  hindered  and  distention  occurs.  Gurgling 
and  spurting  sounds  may  be  heard  at  first,  even  where  no  stenosis  exists 
(bands  and  omental  openings),  but  are  not  so  loud,  and  soon  cease; 
the  percussion  and  auscultatory  findings  (metallic  flat  tones)  are  even 
more  pronounced  than  in  stenosis.  The  vomiting,  an  almost  constant 
concomitant  of  complete  closure,  does  not  come  on  at  once,  but  follows, 
after  a  short  period  of  loss  of  appetite,  eructation  of  bad-smelling  gases 
and  nausea,  within  twenty-four  hours,  or  at  least  not  later  than  forty- 
eight  hours,  unless  the  occlusion  is  seated  low  down  in  the  tract  and 
gradual,  when  five  days  may  elapse  before  the  vomiting.  At  first  the 
contents  of  the  stomach  are  ejected,  and  then,  as  one's  nose  or  the 
Ehrlich  test  for  stercobilin  applied  to  some  of  the  vomitus  will  inform 
us,  the  fecal  matter  is  being  thrown  up.  This  is  the  last  act  in  the 
tragedy,  and  is  always  indicative  of  complete  closure  of  the  lumen, 
if  any  doubt  existed  before.  "With  the  onset  of  fecal  vomiting  the  con- 
dition of  the  patient  becomes  distinctly  worse,  and  then  resembles 
closely  that  of  strangulation,  but  occurs  much  later.  The  eyes  are 
sunken,  the  pulse  rapid  and  weak,  the  hands  and  feet  cold  and  blue,  the 
temperature  is  subnormal,  and,  suffering  intensely  from  thirst,  the 
victim  dies  in  collapse,  usually  in  full  possession  of  his  senses.  When 
occlusion  of  the  small  intestine  takes  place,  the  vomiting  is  earlier. 


610  DISEASES   OF   THE   DIGESTIVE   TRACT 

more  persistent,  and  the  vomitus  often  fails  to  give  the  stercobilin  re- 
action. 

Strangulation  is  particularly  noted  for  the  violence  of  its  onset, 
Avhich  usually  attacks  persons  in  perfect  health.  The  colicky  pains  be- 
come severe  at  once,  are  continuous,  localized  about  the  navel,  and  do 
not  undergo  remissions.  The  evidences  of  shock,  which  in  simple  occlu- 
sion come  on  later,  here  appear  immediately ;  the  face  expresses  great 
anxiety  and  suffering,  the  pulse  is  rapid  and  weak,  the  temperature 
sinks  below  normal,  and  the  extremities  are  like  ice.  The  vomiting  at 
first  consists  of  bile-st-ained  fluid,  often  accompanied  by  hiccough,  and 
later,  without  any  appreciable  intermission,  of  fecal  matter,  and  per- 
sists until  the  end.  Collapse  follows  quickly,  and,  without  relief,  death 
occurs  in  two  to  four  days.  Some  cases  are  not  so  rapidly  fatal,  and 
strangulation,  because  not  complete,  may  persist  several  days  without 
gangrene  of  the  intestine ;  but  after  the  third  day  a  new  danger  arises 
— peritonitis — which  is  equally  as  fatal,  so  that,  if  surgical  aid  is  to  be 
effective,  it  must  be  employed  during  the  first  two  days — of  course 
after  an  assured  diagnosis.  INIeteorism  is  not  marked  at  first  with 
strangulation,  and  visible  peristalsis  is  absent;  the  intestines  are 
"dead,"  as  someone  has  expressed  it.  Still,  "Wahl  has  demonstrated 
that  just  before  the  constriction  very  often  a  short  stretch  of  intestine 
may  be  found  which  has  a  full  elastic  feel,  shows  no  peristalsis,  and  is 
immovable ;  percussion  gives  a  tympanitic  note,  and  shows  this  section 
to  be  moderately  painful.  This  finding  of  a  distended  fixed  portion  of 
the  intestine  applies  only  to  the  very  early  stages,  for  later  a  general 
meteorism  may  be  set  up  or  peritonitis  occur,  and  then  this  peculiar 
condition  is  obscured.  Of  course,  no  passage  of  feces  or  gas  takes  place, 
except  the  little  lying  below  the  narrowing,  and  that  during  the  first 
few  hours,  for  desire  is  always  present,  but  later  it  is  not  uncommon  to 
have  watery  passages  without  fecal  matter,  containing  mucus  and 
blood  from  the  oozing  into  the  lumen  when  the  blood  supply  is  not  fully 
cut  off. 

Invagination  may  resemble  either  occlusion  or  strangulation  to  the 
extent  to  which  its  mesentery  is  carried  between  the  opposed  layers  of 
the  intestine,  and  hence  its  blood  supply  is  cut  off.  The  pain  is  sudden 
and  intense,  localized  with  difficulty,  because  chiefly  in  children,  who 
complain  only  of  a  stomachache ;  the  movements,  which  follow  the  pain 
immediately,  are  first  liquid  and  fecal,  later  consist  largely  of  mucus 
and  blood,  with  very  little  fecal  matter,  and  are  accompanied  with 
severe  tenesmus.  The  vomiting  soon  follows  the  pain,  but  may  subside 
for  a  time;  the  small  patient  refuses  all  food  and  lies  in  a  state  of 


INTESTINAL   STENOSES   AND   OCCLUSIONS  511 

apathy;  pretty  soon  the  discharge  of  fecal  matter  and  gas  ceases, 
though  the  bloody  mucus  continues,  thirst  is  excessive,  and  collapse 
follows.  The  abdomen  is  not  particularly  tender  or  distended,  and 
usually  the  sausage-like  tumor  can  be  detected.  Vomiting  once  more 
sets  in,  becomes  fecal,  and  death  arrives  in  from  five  to  eight  days  if 
surgical  aid  is  not  summoned  or  the  necrosed  portion  cast  off. 

Treatment. — The  treatment  may  be  properly  divided  into  two  stages 
— the  one  applied  to  chronic  stenosis,  where,  for  any  reason,  operation 
is  not  desirable  or  is  declined  by  the  patient ;  the  other  applied  to  those 
instances  of  complete  obstruction  or  occlusion.  In  stenosis  the  diet 
plays  a  very  important  part,  because  those  foods  containing  much 
cellulose  (cabbage,  onions,  beans),  from  the  production  of  gas,  and 
berries  with  seeds,  as  well  as  nuts,  from  their  large  residue,  may  me- 
chanically close  a  small  orifice,  through  which  minutely  divided  food 
material  and  feces  without  large  refuse  have  successfully  made  their 
way.  A  diet  list  follows,  which  has  enabled  us  to  nurse  along  such  pa- 
tients for  long  periods  without  the  dreaded  outcome  of  complete 
closure : 

DIET   LIST   IN    INTESTINAL   STENOSIS 

Breakfast. — A  glass  of  orange  juice  or  grapefruit  juice  sweetened 
with  milk  sugar ;  toast,  a  couple  of  soft  boiled  or  dropped  eggs ;  a  cup 
of  tea  or  coffee,  with  cream,  and  milk  sugar  for  sweetening. 

Midforenoon. — A  cup  of  beef  tea,  with  a  teaspoonful  of  somatose  or 
laibose  stirred  in,  and  a  soda  wafer. 

Dinner. — Soup  (clear  or  thickened  with  flour  only)  ;  beef,  lamb, 
chicken,  or  fish,  minced,  or  put  through  a  meat  cutter  and  all  long 
shreds  and  bits  of  gristle  removed  before  cooking ;  mashed  or  baked  po- 
tato; mashed  squash  or  chopped  spinach,  or  the  same  put  through  a 
sieve ;  any  jelly  without  seeds,  or  apple  sauce,  or  the  interior  of  a  baked 
apple  (avoid  skin,  seeds,  and  cores),  served  with  cream,  or  gelatine  and 
cream ;  a  glass  of  brandy  and  water  after  finishing  the  meal. 

Midafternoon. — A  beaten  egg,  to  which  milk  or  a  dash  of  brandy 
may  be  added. 

Supper. — An  omelet  or  a  bowl  of  custard,  some  soft  cheese  (cream  or 
Neuchatel)  ;  Vienna  rolls  or  French  bread  (on  account  of  the  extensive 
crust),  well  chewed  or  softened  in  the  tea;  a  cup  of  tea,  with  cream 
and  milk  sugar. 

Bedtime. — A  cup  of  beef  tea  or  a  glass  of  milk,  with  a  teaspoonful  of 
somatose  or  laibose  stirred  in. 

The  following  articles  should  be  strictly  forbidden :  cabbage,  salads. 


512  DISEASES   OF   THE   DIGESTIVE   TRACT 

pickles,  raw  fruit,  buttermilk  (on  account  of  the  gas),  Graham  and 
whole  wheat  bread.  Meat  to  be  given  only  if  no  temperature  is  pres- 
ent. 

As  a  portion  of  the  mild  cramps  found  in  incomplete  stenosis  is  due 
to  spasm,  a  nightly  suppository^  of  extractum  belladonnae,  0.02  gram 
(Ys  grain),  and  a  tablespoonful  of  liquid  petroleum  will  often  keep  the 
patient  comfortable  for  a  long  time.  When  ileus  has  set  in,  then  all 
hopes  of  proper  nourishment  are  to  be  given  up ;  the  persistent  vomit- 
ing and  the  dilatation  of  the  small  intestine,  if  the  obstruction  is  situ- 
ated high  up,  allow  only  the  hope  that  some  liquid  nourishment  and 
stimulant — like  albumin  water,  ice  cream,  black  coffee,  beef  tea  and 
well-diluted  brandy — may  be  absorbed  in  sufficient  quantities  to  keep 
up  the  action  of  the  heart.  "When  the  case  is  prolonged  beyond  two  to 
three  days  and  the  symptoms  have  somewhat  subsided,  we  may  proceed 
to  rectal  alimentation.  Subcutaneous  or  rectal  injections  of  physio- 
logical salt  solution  may  also  be  employed  to  combat  the  intense  thirst 
from  which  the  victims  suffer.  The  continuous  administration  method 
or  proctoclysis  is  indicated,  but  the  patients  often  complain  so  bitterly 
of  the  restraint  that  this  application  demands  that  it  is  often  better 
to  put  into  the  rectum  250  c.c.  at  a  time,  which  is  usually  immediately 
absorbed.  Another  means  which  often  acts  miraculously  is  gastric 
lavage.  It  diminishes  the  intragastric  pressure,  encourages  the  flow 
of  the  contents  of  the  small  intestine  into  the  stomach,  thereby  reliev- 
ing the  distention  by  gas,  and  by  that  very  means  lessening  the  con- 
striction if  external.  The  lavage  should  be  repeated  every  three  to 
four  hours.  Rectal  injections  for  purely  mechanical  purposes  are  of 
little  avail  if  the  obstruction  is  in  the  small  intestine,  for  the  fluid  can 
rarely  be  made  to  pass  beyond  the  ileocecal  valve,  nor  can  it  do  more 
than  increase  the  twist  in  a  volvulus  of  the  colon,  but,  when  there  is  an 
obstruction  from  packed  feces  or  an  invagination,  the  water  may  soften 
the  mass  and  stimulate  peristalsis  in  the  one  case  or  disinvaginate  the 
intestine  in  the  other  if  employed  very  early.  For  the  latter  puri:)ose 
air  may  also  be  employed  advantageously,  introduced  through  a  colon 
tube  with  a  bulb  syringe.  Whether  such  irrigations  can  penetrate  an 
organic  stricture  to  such  an  extent  as  to  soften  feces  packed  above  it 
is  uncertain,  although  in  an  old  man  in  whom  a  malignant  stenosis 
seemed  assured,  with  obstruction  of  twenty-four  hours'  duration,  but 
no  strangulation,  six  enemata  of  1  liter  each  were  given  at  four-hour 
intervals  in  the  knee-chest  position  before  the  first  fragments  of  fecal 
matter  appeared.  Whenever  such  copious  enemata  are  given,  it  is  very 
necessary  to  note  whether  all  or  a  large  part  of  the  fluid  is  returned 


INTESTINAL   STENOSES   AND   OCCLUSIONS  513 

before  any  more  is  given,  lest  the  colon  be  overdistended  and  ruptured. 
To  these  injections  the  usual  substances  may  be  added — salt,  soap,  olive 
oil,  and  glycerine ;  in  fact,  each  of  these  may  be  tried  in  turn  in  order 
to  free  the  impaction.  \Yith  the  soda  water,  applied  by  attaching 
the  nozzle  of  a  siphon  to  the  colon  tube,  we  have  had  no  experience, 
although  this  method  has  its  adherents.  Massage  can  never  be  justi- 
fiable except  in  fecal  impaction,  and  then  only  when  there  is  absolute 
evidence  of  no  peritoneal  involvement.  The  employment  of  drugs 
often  plays  an  important  part,  but  the  first  thing  to  learn  is  that 
purgatives  must  never  be  used  in  any  form  of  ileus,  except  the  fecal 
impaction,  and,  as  this  always  occurs  in  the  colon,  irrigation  will  ac- 
complish the  same  purpose,  with  less  danger  and  discomfort.  When 
used  for  any  other  form,  laxatives  simply  increase  the  peristaltic  storm, 
and  the  fecal  matter  is  packed  more  closely  about  the  narrow  open- 
ing, the  intestine  becomes  more  distended,  and  rupture  has  been  known 
to  take  place.  Thus  the  warning  to  all  medical  men  should  be,  "Purga- 
tives are  forbidden  in  acute  ileus."  Opium  also  serves  an  admirable 
purpose  in  the  early  stages  by  checking  the  restlessness,  spasm,  nausea, 
and  vomiting,  which  allow  the  patient  no  rest,  but  after  this  violent  on- 
set is  partially  overcome,  the  point  is  reached  where  the  opiate  should 
be  withdrawn,  because  it  masks  the  symptoms  and  gives  a  false  sense 
of  security.  Apart  from  its  sedative  effect  on  the  patient,  opium  un- 
doubtedly quiets  the  spasm  of  the  intestine,  which,  by  allowing  no  re- 
laxation, prevents  kinks,  twists,  and  invaginations  from  becoming  spon- 
taneously released  and  the  intestines  restored  to  their  normal  position. 
The  rule  must  be  followed,  however,  never  to  give  another  dose  until 
restlessness  and  pain  show  that  the  effects  of  the  previous  one  have 
ceased,  and  it  should  be  wholly  withdrawn  after  twenty-four  hours, 
unless  a  decision  not  to  operate  has  been  reached,  when  it  may  be  con- 
tinued, of  course,  to  the  fatal  termination  in  order  to  aid  euthanasia. 
The  extractum  opii,  in  suppositories  of  0.05-0.1  gram  (I-II/2  grains), 
must  be  used,  or,  if  the  vomiting  is  not  a  prominent  feature,  20  drops 
of  tinctura  opii  deodorati  may  be  employed  until  its  full  effect  is  pro- 
duced. These  increased  doses  of  opium  are  far  superior,  for  some  un- 
known reason,  to  morphine,  in  relaxing  spasm.  The  patient's  per- 
sistent claims  that,  under  the  influence  of  the  opiate,  his  ills  have  de- 
parted and  he  is  recovering  should  never  deceive  the  physician.  The 
recurrence  of  passage  of  flatus  and  feces  is  the  only  criterion  of  the  res- 
toration of  the  integrity  of  the  lumen.  In  recent  years  most  favorable 
reports  have  been  coming  in  of  the  beneficial  action  of  atropine  in  re- 
lieving ileus  by  checking  the  tendency  of  the  intestine  to  paresis  as 


514  DISEASES   OF   THE    DIGESTIVE   TRACT 

well  as  overcoming  spasm.     After  the  first  twenty-four  hours'  treat- 
ment with  opium,  if  no  relief  of  the  obstruction  has  occurred,  a  hypo- 
dermic injection  of  0.002  gram   (i^o  grain)   may  be  employed,  and 
twelve  hours  later,  if  unrelieved,  another  injection  of  0.003  gram  (^20 
grain)  should  follow.     AVhen,  after  forty-eight  hours  of  the  combined 
use  of  opium  and  atropine,  no  passage  of  feces  or  gas  has  taken  place, 
a  laparotomy  is  our  only  refuge.     Poisonous  symptoms  from  these  large 
doses  rarely  occur  on  account  of  the  previous  use  of  opium.     When  we 
are  dealing  with  paresis  of  the  intestine  only,  as  after  surgical  opera- 
tion and  mesenteric  embolism,  and  are  assured  that  no  constriction 
exists,  we  may  employ  physostigmine  salicylate  hypodermically   in 
0.0005-gram    (1.420-grain)    doses  with  success,  as  well  as  the  newer 
preparation,  hormonal,  intravenously,  but  they  must  never  be  used 
where  the  intestine  is  pinched  or  narrowed,  for  their  use  is  wholly  to 
stimulate  peristalsis.     This  practically  completes  what  we,  as  internists, 
can  accomplish  for  the  release  of  ileus,  and  ordinarily  we  have  only 
forty-eight  hours  in  which  to  accomplish  it.     If  we  maintain  medical 
treatment,  except  in  very  few  instances,  beyond  that  period  and  then 
turn  the  case  over  to  a  surgeon,  we  have  ourselves  sinned  and  also  put 
an  extra  burden  on  his  shoulders.     Even  if  we  are  not  exactly  sure  of 
the  condition  in  the  abdomen  of  our  patient,  the  time  given  for  this 
study  cannot  be  prolonged.     Schnitzler  says  that  an  operation  under 
false  diagnosis  at  the  right  moment  is  better  than  an  operation  under 
the  right  diagnosis  at  the  false  moment.     Delay  in  operation  is  nat- 
urally more  justifiable  in  occlusion  from  fecal  impaction — gallstones 
and  invagination — than  in  strangulation  and  kinks,  where  the  violence 
of  the  symptoms  indicate  the  urgency  of  immediate  action.     On  the 
contrary,  when  the  signs  of  diffuse  peritonitis  appear,  it  is  too  late  for 
surgery,  and  all  we  can  do  is  to  make  the  last  hours  of  the  patient  as 
painless  as  possible.     This  decision,  however,  should  not  rest  on  the 
judgment  of  the  physician  alone,  but  on  the  conjoint  advice  of  a  sur- 
geon, noted  not  so  particularly  for  brilliant  operations  as  for  his  sound 
opinion.     The  general  condition  of  the  patient  will  always  remain  an 
important  guide  as  to  the  need  of  haste  in  operation.     If  the  pulse  re- 
mains not  over  100,  meteorism  is  not  increasing,  and  vomiting  has 
ceased — provided,  of  course,  the  patient  is  not  stupefied  with  opium — 
we  may  delay  with  safety,  but  all  preparations  must  be  made  for  opera- 
tion or  transfer  of  the  patient  to  a  hospital  if  one  is  near.     As  in  ap- 
pendicitis, if  at  all  severe,  it  is  much  wiser  for  the  internist  to  call  a 
surgeon  early  and  share  the  burden  of  the  question,  "to  be  or  not  to 
bo  "  with  him. 


CHAPTER  XX 

MALIGNANT  GROWTHS  OF  THE  INTESTINE 

In  the  opinion  of  the  majority  of  physicians  this  designation  will  al- 
ways mean  carcinoma — first,  because  the  physician  usually  distin- 
guishes only  between  benign  and  malignant  tumors,  and,  second,  be- 
cause such  an  enormous  percentage  of  these  growths  is  carcinomatous. 
With  the  fine  distinctions  of  sarcoma,  adenoma,  and  myoma  he  is  unac- 
quainted. We  are  no  more  familiar  with  the  causation  of  cancer — to 
use  the  generic  and  popular  term — of  the  intestine  than  of  the  stomach. 
We  do  observe,  however,  that  the  straight  stretches,  where  partially 
digested  food  and  fecal  matter  pass  rapidly  and  smoothly,  cancer  does 
not  attack,  but  at  the  points  where  physiological  stasis  exists  or  passage 
is  slowed  and  made  more  difficult — the  rectum,  cecum,  colon  flexures, 
and  duodenum — the  growth  is  usually  found,  but  whether  incited  by 
mechanical  or  chemical  irritation  cannot  be  told.  The  lower  rectum, 
too,  with  its  hemorrhoids,  and  the  sigmoid,  with  its  surplus  of  hardened 
feces  in  constipation,  are  both  inviting  for  the  growth  of  malignant  dis- 
ease. It  is  in  this  region  also  that  a  polypus,  at  first  bland  and  harm- 
less, becomes  so  often  the  site  for  cancerous  degeneration.  Blows  in  the 
abdomen  and  other  injuries  in  that  region  have  been  adduced  as  a  cause 
for  cancer,  but  probably  the  connection  is  not  more  close  than  that  be- 
tween the  falls  of  small  children  and  subsequent  tubercular  spinal 
caries,  for  there  are  but  few  of  these  victims  from  cancer  who  cannot 
remember  an  injury  within  a  reasonable  period  of  time.  In  frequency 
the  cancer  of  the  intestine,  based  on  statistics  of  large  hospitals,  forms 
one-fifth  of  the  malignant  growths  of  the  entire  digestive  tract.  It  has 
also  been  the  impression  of  many  physicians  in  large  clinics  that  the 
number  of  intestinal  cancers  is  steadily  increasing,  but  A.  Schmidt  re- 
marks that  this  is  probably  only  relative — that  is,  in  proportion  to  other 
diseases,  like  tuberculosis  and  infectious  fevers,  which  are  diminishing 
under  the  prophylactic  campaign  of  the  profession,  while  it  stands 
helpless  before  cancer,  and,  we  may  add,  which  will  continue  until 
something  is  known  in  regard  to  its  origin.  ]\Ien  are  undoubtedly 
more  often  attacked  than  women,  which  is  particularly  true  of  low- 
lying  growths  (rectal  and  sigmoid),  while  as  we  ascend  the  tract  the 

515 


516  DISEASES   OF   THE   DIGESTIVE   TRACT 

difference  between  the  sexes  disappears.  As  with  cancer  in  other  situa- 
tions, the  years  from  40  to  56  are  most  prone  to  these  growths,  though 
they  are  not  unknown  in  younger  persons;  in  fact,  fifty  cases  were 
collected  by  one  author  in  which  the  patients  were  less  than  20  years 
of  age.  Practically  all  of  the  cancers  found  in  the  intestine  are 
primary,  though  occasionally  the  rectum  is  involved  by  metastasis  when 
that  disease  exists  in  the  stomach  or  gallbladder. 

The  gross  appearance  of  cancer  may  be  nodular  excrescences,  with 
smooth  surface,  cauliflower-like  forms,  easily  bleeding,  or  hard  infiltra- 
tions of  the  intestinal  wall.  Very  often  interstitial  tissue  increases  so 
rapidly  that,  from  the  contraction  produced  by  it,  the  gut  is  con- 
stricted and  shortened;  here  the  symptoms  of  stenosis  overshadow  all 
the  others.  Again,  the  polypoid  form  rapidly  leads  to  invagination, 
while  its  surface  becomes  ulcerative  from  the  constant  contact  with 
stagnating  fecal  matter.  These  are  usually  superficial,  but  they  may 
deepen  and  lead  to  perforation  of  the  wall.  For  this  reason,  too,  a 
cancer  may  run  its  course  without  any  evidence  of  narrowing.  Puru- 
lent collections  may  form,  to  which  the  patient  reacts  with  a  tempera- 
ture, and,  if  situated  in  the  ileocecal  region,  the  mass  may  be  taken 
for  an  appendicitis  or  a  tuberculous  affair.  Acute  diffuse  peri- 
tonitis rarely  accompanies  an  extension  of  a  new  growth  beyond  the 
intestinal  wall,  but  much  oftener  the  chronic  form  occurs,  with  marked 
effusion  into  the  peritoneal  cavity,  which  may  be  either  chylous  or 
blood  stained.  When  the  growth  has  once  made  its  way  through  the 
wall  to  the  peritoneum  by  continuity,  it  may  extend  to  adjacent  organs, 
with  the  formation  of  fistulae,  and  we  may  have,  for  instance,  a  gastro- 
colic or  a  rectovaginal  communication.  Intestinal  cancers  are  slow  to 
form  metastases,  though  those  of  the  rectum  should  be  excluded  from 
this  statement  in  later  stages.  In  its  early  course  the  growth  can  be 
removed  with  every  assurance  that  the  lymph  glands  are  not  involved. 
When  metastases  do  take  place,  the  glands  are  the  first  affected,  then 
the  peritoneum,  then,  in  order,  the  omentum,  lungs,  and  kidneys. 

Symptoms. — The  symptoms  must  necessarily  depend  on  the  location 
of  the  growth  and,  while  stenosis  is  the  same  in  all  cases,  yet  in  some 
instances  the  general  condition  may  force  these  evidences  into  the  back- 
ground. Among  these  features  is  a  progressive  anemia  of  the  char- 
acter which  we  call  secondary.  This  is  probably  aided  by  the  inflam- 
matory disturbance  of  the  canal  above  the  stenosis,  for  in  cancer  of  no 
organ,  except  the  stomach,  is  this  anomaly  of  the  blood  so  marked 
as  in  intestinal.  The  reasons  for  this  must  be  sought  in  the  absorption 
of  infectious  agencies  and  toxic  material,  as  well  as  in  the  repeated  loss 


MALIGNANT   GROWTHS   OF    THE   INTESTINE  517 

of  small  amounts  of  blood  in  the  feces.  While  ordinarily  this  anemia 
follows  the  same  course  as  any  other  accompanying  a  constitutional  dis- 
ease— like  tuberculosis,  for  example — yet  at  times  the  picture  pre- 
sented closely  resembles  pernicious  anemia  in  the  variety  of  erythro- 
cytes, their  diminished  number,  and  the  color  index  of  the  blood.  This 
anemia  is  usually  early  developed  in  some  cases  long  before  local  con- 
ditions give  us  an  inkling  as  to  the  presence  of  a  growth,  while  in 
others  the  anemia  is  very  late  in  making  its  onset  when  palpation 
clearly  shows  why  the  latter  is  present.  Accompanying  the  anemia  we 
may  have  emaciation  and  marked  loss  of  weight,  though  one  is  often 
surprised  at  the  excellent  state  of  nourishment  in  which  many  of  the 
victims  of  intestinal,  particularly  of  colon  cancer  are  as  compared  with 
the  gastric  form.  On  the  peculiar  cachexia  which  cancer  patients  were 
supposed  to  possess,  one  can  put  but  little  dependence,  for  it  does  not 
differ  markedly  from  that  of  pernicious  anemia,  and  advanced  cases 
of  malignant  disease  paay  show  only  the  deathly  pallor  of  secondary 
anemia.  Apart  from  these  general  symptoms,  we  must  rely  on  the 
local  conditions  for  our  diagnosis,  and,  instead  of  taking  them  in 
anatomical  order  from  the  stomach  on,  we  will  consider  these  new 
growths  in  order  of  their  frequency.     , 

RECTAL  CANCER. 

Rectal  cancer  includes  those  situated  as  high  up  as  the  rectopelvic 
fold,  and  hence  may  not  be  reached  by  digital  examination,  but  can 
always  be  seen  through  the  rectoscope.  The  pain  experienced  is  not 
often  of  a  colicky  character  and  situated  in  the  abdomen,  but  a 
tenesmus,  which  is  persistent  and  unrelieved  by  defecation.  The  pain 
may  also  be  felt  in  the  lower  back,  and  stream  to  the  genitals  and  down 
the  outer  thighs.  There  are  few  evidences  of  the  stenosis,  except  early 
constipation  with  packed  rectum,  and  later  frequent  and  fragmentary 
stools,  sometimes  termed  * '  fractional. ' '  The  stools  may  be  tape  or  lead 
pencil  form,  or  in  the  shape  of  scybala,  or  possibly  cylindrical,  or, 
from  the  excessive  secretion  above  the  cancer,  may  be  the  simple  liquid 
diarrheal  stool  of  colon  catarrh.  Blood-stained  mucus  in  abundance 
is  always  present,  and  many  discharges  will  contain  no  fecal  matter 
whatever.  Pure  blood  will  never  be  found  with  cancer  unless  compli- 
cated with  or  the  outcome  of  hemorrhoids.  There  is  unquestionably  a 
peculiarly  putrid  odor  to  these  stools  which  are  found  in  low-lying 
colon  cancers  where  ulceration  has  begun  that,  in  our  mind,  is  not  simu- 
lated by  any  of  the  discharges  closely  allied  in  gross  appearance  found 


518  DISEASES   OF   THE   DIGESTIVE    TRACT 

in  dysentery,  ulcerative  colitis,  etc.  The  same  odor  can  also  be  de- 
tected on  the  patient,  no  matter  how  careful  he  may  be  in  regard  to 
personal  cleanliness,  which  Zweig  says  is  due  to  spots  of  bloodj^  mucus 
which  adhere  to  the  linen  in  spite  of-  the  greatest  care  observed  by  the 
patient.  Ordinarily  a  digital  examination  will  detect  the  growth, 
whether  as  a  hardening  at  one  side,  a  mulberrj^-like  growth  extending 
into  the  lumen,  or  a  rigid  narrowing  just  beyond,  but  feeling  as  if  coex- 
istent with  the  sphincter.  To  make  this  examination  to  the  best  ad- 
vantage, however,  the  rectum  must  be  emptied  by  an  enema,  the  patient 
placed  on  his  back  or  side,  with  knees  drawn  up,  while  in  the  latter 
case  the  hand  is  placed  between  the  thighs  and  the  finger  introduced 
with  its  convexity  coincident  with  the  curve  of  the  coccyx.  Unfor- 
tunately, however,  we  can  not  reach  beyond  10  cm.,  and  some  of  us  even 
less  than  that,  and  the  rectoscope  must  be  called  into  play  to  reach  the 
growth.  This  may  require  a  cocainization.  If  the  rectoscope  is  not 
available,  after  etherizing  the  patient  and  dilating  the  sphincter,  we 
may  reach  high  enough  to  palpate  the  growth.  We  always  have  to  dif- 
ferentiate such  changes  from  tuberculosis,  syphilis,  proctitis,  periproc- 
titis, and  chronic  ulcerative  colitis,  and,  when  the  gross  appearance 
alone  does  not  give  us  the  desired  information,  a  small  section  must 
be  removed  for  microscopic  examination.  It  is  also  necessary,  so  far 
as  possible,  to  determine  the  size,  the  degree  of  adhesion,  and 
movability  of  the  growth  with  reference  to  other  organs  in  the  pelvis. 
It  has  often  surprised  us,  when  palpation  showed  a  circumscribed  and 
apparently  pendulous  malignant  growth,  whose  upper  limit  one  could 
perceptibly  reach  with  the  finger,  to  find  the  surgeon  doing  a  Kraske 
operation  to  attain  to  its  superior  surface  and  complete  its  eradication. 
Such  growths,  too,  often  become  adherent  to  the  bladder  and  vagina 
and  break  into  them,  but  a  periproctitis,  fistula,  or  peritoneal  metas- 
tasis is  rare,  though  the  liver  may  be  easily  involved.  ^Metastasis  in 
the  pouch  of  Douglas,  secondary  to  a  malignant  growth  of  the 
stomach,  must  not  be  taken  for  a  primary  invasion. 

COLON  CANCER. 

Colon  cancer  has  symptoms  which  do  not  differ  at  first  from  those 
which  have  been  described  for  chronic  stenosis.  In  its  earliest  stage 
there  is  a  feeling  of  distention  or  fullness  at  some  locality  in  the  ab- 
domen, which  is  not  necessarily  the  site  of  the  gi'owth.  This  is  exag- 
gerated at  times  during  the  day  to  actual  pain,  either  following  in- 
gestion of  food  or  previous  to  stool,  which  relieves  it.     This  pain  may 


MALIGNANT    GROWTHS   OF   THE   INTESTINE  519 

increase  from  day  to  day  until  it  is  a  veritable  colic,  without  any  sus- 
picion on  the  part  of  the  physician  of  malignant  disease,  and  colic  may 
occur  suddenly,  accompanied  by  vomiting  or  even  acute  ileus,  brought 
on  by  obstruction  of  the  narrowed  passage  from  the  coarse  fibers  of 
asparagus,  celery,  or  from  other  food  containing  much  cellulose.  The 
next  thing  which  attracts  our  attention  is  either  a  moderate  gaseous  dis- 
tention of  the  abdomen  or  spasmodic  filling  of  a  section  of  the  colon — 
for  instance,  the  transverse  or  cecum  when  the  cancer  is  at  the  sigmoid, 
accompanied  by  pain.  These  grow  so  very  slowly,  however,  and  the 
narrowing  accompanying  them  is  so  gradual,  that  even  in  advanced 
stages,  where  the  tumor  can  be  easily  felt,  no  distinctive  inflation  or 
rigidity  can  be  discovered,  and  yet  the  periodical  attacks  of  pain  are 
rarely  wanting.  In  order  to  produce  these  exaggerated  contractions, 
an  enema  of  cold  water  has  been  recommended.  One  of  the  most  sug- 
gestive signs  is  the  frequent  occurrence  of  mild  obstruction  in  old  peo- 
ple, which  we  often  diagnose  as  ' '  impacted  feces, ' '  and  relieve  by  mild 
laxatives  and  enemata,  without  a  suspicion  that  we  are  dealing  with  a 
malignant  disease  until  an  attack  more  severe  than  the  others  is  unre- 
lieved by  this  simple  treatment,  and  an  operation  shows  a  well-advanced 
cancerous  narrowing.  Sometimes  gastric  symptoms — anorexia,  eructa- 
tions, distress  after  eating,  and  heartburn — are  most  prominent,  and 
lead  us  to  regard  the  malignant  growth  as  one  of  the  stomach,  which 
has  been  accounted  for  by  a  marked  delay  in  the  emptying  of  the 
latter,  particularly  when  the  ileocecal  opening  was  involved.  There  is 
at  first  a  marked  restriction  in  the  number  and  quantity  of  the  stools, 
which  in  a  person  over  40  years  of  age,  w^hose  habits  heretofore  have 
always  been  regular  in  this  respect,  accompanied  perhaps  by  occasional 
colic,  should  always  arouse  our  suspicions  of  a  malignant  growth, 
M'hich  only  the  most  painstaking  examination  can  allay  or  confirm. 
Eventually,  as  colitis  sets  in  above  the  constriction,  frequent  liquid 
stools  occur,  which  are  always  filled  with  mucous  shreds,  blood,  and 
often  pus,  much  as  would  be  found  in  a  dysentery.  One  distinction 
from  the  latter  is  that  in  cancer  of  the  colon  the  stools  suddenly  change 
their  character  and  become  hardened  and  formed.  Cases  have  come 
under  our  observation,  however,  where  frequent  liquid  stools  persisted 
during  the  whole  course  of  the  disease.  Small  quantities  of  blood,  de- 
tected only  by  chemical  means,  are  an  early  and  frequent  accompani- 
ment of  cancer  and  can  be  fully  utilized  in  diagnosis.  Large  quanti- 
ties of  blood  as  are  found  in  hemorrhoids,  however,  are  rare,  and  at 
best  only  a  few  bloody  streaks  may  be  noted  mixed  with  the  stool, 
associated  alwa^'s  with  mucus  and  pus. 


520  DISEASES   OF   THE   DIGESTIVE   TRACT 

The  detection  of  the  tumor  mass  is,  of  course,  a  positive  proof  of 
the  pathologic  condition,  but  this  is  possible  in  probably  not  more 
than  half  of  the  cases  owing  to  its  position  under  the  liver — the  fact 
that  the  type  (scirrhous)  does  not  produce  a  large  growth  nor  a  spasm 
of  the  abdominal  muscles.  To  satisfactorily  palpate  such  a  tumor,  the 
intestine  must  be  emptied  by  an  enema  or  mild  laxative,  for  an  ac- 
cumulation of  fecal  matter  or  gas  sadly  interferes  with  this  detection 
by  the  fingers.  These  tumors  are  noted  for  their  motility.  Not  only 
by  the  change  of  position  of  the  patient,  but  by  the  examiner 's  fingers, 
can  they  be  moved  about,  particularly  where  their  mesentery  allows 
freedom,  as  at  the  sigmoid,  cecum,  and  transverse  colon.  Advan- 
tageous aids  for  bringing  the  tumors  more  distinctly  under  the  fingers 
have  been  suggested,  such  as  inflating  the  colon  mth  air  by  means  of  a 
syringe,  or  placing  the  patient  in  a  hot  bath  during  examination.  This 
motility  is  only  a  feature  when  no  adhesions  have  formed,  and  it  often 
happens  that  acquired  or  congenital  anomalies  of  position,  as  well  as 
pressure  of  a  distended  intestine  above,  so  distorts  the  site  of  the 
tumor  that  mistakes  are  often  made  as  to  its  anatomical  relations. 
Adhesions  to  the  uterus,  bladder,  and  kidney  are  not  uncommon  and 
confuse  the  diagnosis;  growths  of  the  transverse  colon,  as  well  as  its 
upper  flexures,  move  with  respiration,  and  also  those  of  the  stomach 
when  nonadherent.  The  growth  itself  is  noted  for  its  extreme  hard- 
ness, while  its  surface  may  be  smooth  or  nodular.  Its  size  varies  from 
a  walnut  to  that  of  a  grapefruit,  and  is  usually  overestimated  by  palpa- 
tion for  the  portion  of  the  intestine  above  it,  especially  if  beyond  the 
center  of  the  transverse  colon,  where  the  feces  begin  to  solidify,  is 
filled  with  hardened  fecal  matter,  whose  consistence  is  difficult  to  dif- 
ferentiate from  the  mass,  so  that  their  volume  is  reckoned  with  it. 
These  tumors  are  tender,  and  sometimes  painful  to  touch,  though  rarely 
we  find  one  which  apparently  has  no  sensitiveness.  So  much  depends 
on  the  correct  interpretation  of  any  mass  found  in  the  abdomen  that  a 
word  must  be  repeated  in  regard  to  the  confusion  of  malignant  growths 
with  fecal  tumors.  The  sensation  of  touch  is  much  the  same.  Palpa- 
tion of  the  latter  may  produce  pain  from  an  conjoint  localized  colitis, 
and  the  secondary  fecal  tumor  mentioned,  which  forms  before  the  con- 
striction, will  often  disappear  under  the  influence  of  laxatives,  as  well 
as  a  true  fecal  impaction,  so  that,  after  any  obstruction  has  been  re- 
lieved, particular  pains  must  be  taken  to  detect,  if  possible,  a  small  in- 
testinal growth.  This  need  not  necessarily  be  malignant ;  in  fact,  it  is 
sometimes  found  to  be  tuberculous.  This  is  particularly  true  of 
tumors  at  the  ileocecal  valve,  which  can  sometimes  be  differentiated  by 


MALIGNANT   GROWTHS   OF   THE   INTESTINE  521 

the  detection  of  tubercular  bacilli  in  the  fecal  mucus,  as  well  as  by 
the  diazo  reaction  of  the  urine,  and  purulent  appendicitis  may  cause 
difficulty  particularly  where,  without  any  violent  pain,  a  tumor  sud- 
denly appears  with  rise  of  temperature,  as  in  a  ease  under  our  observa- 
tion, where  a  surgeon  declined  to  operate,  and  on  the  fifteenth  day 
both  the  mass  and  temperature  disappeared  simultaneously.     Here  the 


Fig.  84. — Radiogram  of  cancer  of  the  descending  colon   (bismuth  ingested).      (Collection  of 

Dr.  Arial  W.  George.) 

diagnosis  of  probable  malignant  disease  had  been  made  by  another 
physician.  The  x-ray  examination  offers  marked  aid  in  establishing 
the  presence  of  a  stenosis,  but  apart  from  that  we  can  learn  little;  in 
other  words,  the  peculiar  contour  of  the  lumen  cannot  be  utilized  as 
in  the  stomach  in  favor  of  cancer.  The  bismuth  may  be  introduced 
by  enema  or  ingested,  and  in  the  latter  case  the  accumulation  before 


522 


DISEASES   OF   THE   DIGESTIVE   TRACT 


the  narrowing  and  absence  beyond  usually  indicate  its  size.     The  re- 
verse is  true  when  enema  is  employed. 

Accompanying  symptoms  due  to  other  organs  are  very  common — for 


Fig.  85. — Radiogram  of  cancer  of  the  hepatic  flexure  of  the  colon   (bismuth  ingested). 
(Collection  of  Dr.  Arial  W.  George.) 


instance,  pressure  of  the  tumor  mass  and  distended  coils  of  intestine 
often  produce  vesical  tenesmus,  and  the  entrance  of  the  bacilli  coli 
communis  sets  up  cystitis.     Again,  the  act  of  defecation  may  cause 


MALIGNANT   GROWTHS   OF    THE   INTESTINE  523 

such  violent  contraction  of  the  bladder  that  both  feces  and  urine  are 
passed  together.  ^Mention  has  already  been  made  of  communication 
between  the  intestine  and  the  bladder,  by  which  fecal  matter  is  passed 
by  the  urethra,  and  microscopic  examination  of  the  urinary  sedi- 
ment will  show  both  meat  fibers  and  Clostridium,  which  is  stained  blue 
by  iodine,  and  found  ordinarily  only  in  the  intestine.  Discharge  of 
flatus  by  the  patient  through  the  urethra  is  also  described.  Localized 
invasion  of  the  peritoneum  by  colon  cancers  with  abscess  formation, 
which  may  break  through  the  abdominal  wall,  is  known  and  often  re- 
garded as  purulent  collections,  starting  from  the  appendix  or  Fallopian 
tube,  until  their  true  nature  is  discovered.  Secondary  involvement  of 
the  liver,  too,  by  forming  nodules  may  start  us  on  the  wrong  track  as 
to  the  primary  growth. 

CANCER  OF  THE  DUODENUM. 

Cancer  of  the  duodenum  is,  of  course,  extremely  rare,  but,  when  it 
occurs,  follows  the  annular  form  of  cancer  of  the  colon,  causing  stric- 
ture. The  symptoms  differ  decidedly,  however,  in  that  they  are  more 
like  those  of  gastric  new  growth — nausea,  eructation,  vomiting,  some- 
times hematemesis — and  sooner  or  later  the  gastric  contents  are  in- 
variably accompanied  by  bile  and  disturbances  of  stool,  or  marked 
signs  of  stenosis  occur  very  late  in  the  progress  of  the  disease.  The 
pain  is  usually  in  the  right  upper  half  of  the  abdomen,  the  patient  be- 
comes anemic  and  emaciated,  and  sometimes  one  is  fortunate  enough 
to  discover  a  small  growth  in  this  region,  which,  in  distinction  from 
the  early  gastric  tumor,  is  much  less  movable  or  even  fixed.  Jaundice 
is  frequently  associated,  and,  as  in  a  case  recently  under  our  care, 
where  no  tumor  could  be  found,  gastric  stenosis  was  present  with 
digested  blood,  free  hydrochloric  acid  persisted  with  sareinaj,  and  the 
liver  was  enlarged.  In  such  a  case  diagnosis  becomes  unusually  diffi- 
cult or  impossible.  In  this  instance  a  diagnosis  of  duodenal  growth 
at  the  papilla  was  made,  and  subsequent  autopsy  at  the  Brigham  Hos- 
pital showed  primary  cancer  at  the  head  of  the  pancreas  and  secondary 
involvement  of  the  bile  ducts.  The  stasis  was  due  to  pressure  on  the 
duodenum,  and  the  blood  to  the  oozing  of  the  hemoglobin  released  by 
the  action  of  the  cholalic  acid  on  the  red  blood  corpuscles.  It  might 
equally  as  well  have  been  a  new  growth  of  the  pancreas,  gallbladder, 
or  pylorus  as  far  as  the  symptoms  were  concerned.  Hydrochloric 
acid  may  persist  in  the  stomach  until  death  or  be  found  wanting,  so 
that  it  has  no  diagnostic  value. 


524  DISEASES  OF   THE   DIGESTIVE   TRACT 

CANCER  OF  THE  SMALL  INTESTINE. 

Cancer  of  the  small  intestine,  other  than  the  duodenum,  is  very 
rare,  and  its  diagnosis  during  life  still  rarer.  A  palpable  mass  may 
be  absolutely  wanting,  and  only  the  increasing  pallor  and  emaciation 
attract  attention  to  the  fact  that  the  patient  is  seriously  ill.  The 
stenosis  grows  very  slowly,  and  its  first  evidences  may  be  alternation 
of  constipation  and  diarrhea.  Later  spasmodic  and  irregular  pains 
situated  near  the  navel  are  experienced,  and  there  may  be  a  localized 
gaseous  distention  and  spurting  sounds.  Occasionally  attention  is  not 
called  to  the  intestine  as  the  source  of  the  secondary  anemia  until  a 
complete  occlusion,  with  early  vomiting,  indicates  clearly  where  the 
trouble  lies  and  its  causation.  A  large  amount  of  blood  seldom  occurs 
in  the  stool,  and  cases  reported  have  been  too  few  to  give  us  any  idea 
as  to  the  frequency  of  "occult  blood." 

Diagnosis  in  one  of  its  most  difficult  fields  in  the  realm  of  medicine 
may  allow  one  to  recapitulate  some  of  the  most  suggestive  factors  in 
the  detection  of  intestinal  cancers.  As  the  duodonal  form  is  closely 
allied  to  that  of  the  stomach,  and  the  jejunoileal  rare  and  seldom  de- 
tected, w^e  turn  our  attention  to  the  most  frequent — those  of  the  rectum 
and  colon.  Discharge  of  mucus  and  blood  in  an  elderly  individual 
must  never  be  regarded  as  an  outcome  of  dysentery  or  hemorrhoids 
without  investigation,  for  it  may  as  often  accompany  a  cancer  of  the 
rectum  or  sigmoid.  Colics  in  elderly  people  who  have  been  free  from 
them  during  life  (especially  after  coarse  food)  cannot  be  attributed  to 
constipation,  though  that  may  be  present,  but,  if  lead  poisoning,  tuber- 
culosis, and  syphilis  can  be  excluded,  must  always  arouse  suspicion  of 
malignant  growth.  A  mass  at  or  near  the  cecum,  accompanied  by 
temperature,  without  the  violent  onset  of  appendicitis,  will  always  in 
people  of  a  certain  age  cause  much  uncertainty,  unless  an  absolutely 
definite  history  of  previous  perfect  health  can  be  obtained — often 
a  difficult  thing — or,  as  in  the  case  mentioned  above,  the  mass  disap- 
pears. Cancer  of  the  hepatic  flexure  is  particularly  prone  to  be  diag- 
nosed as  cholelithiasis,  since  no  jaundice  is  necessary  to  prove  the  ex- 
istence of  the  latter,  and  pain  in  the  right  back  is  common  to  both. 
The  attacks  of  gallstone  colic  are  almost  never  dependent  on  food,  and 
are  extremely  erratic  in  their  onset,  while,  in  colon  cancer,  pain  is 
fairly  regular  and  can  usually  be  aroused  by  food,  either  directly  or 
two  hours  after  a  meal,  by  certain  positions  (lying  down  after  a  meal), 
and  there  is  the  usual  absence  of  rise  of  temperature  or  chill  during 
an  attack.     It  is  rare,  too,  that  cancer  of  the  colon  will  not  cause 


MALIGNANT   GROWTHS   OF   THE   INTESTINE  525 

changes  in  the  character  of  the  stools,  which  cholelithiasis  will  not  do, 
unless  the  common  duct  is  blocked. 

Tumors  in  either  lumbar  region  require  some  study  to  differentiate 
their  association  with  the  colon  or  kidney.  If  with  the  former,  there  is 
usually  a  peritoneal  rub  and  occult  hemorrhage,  while  ordinarily  the 
colon  can  be  rolled  over  a  retroperitoneal  growth.  Inflation  of  the 
colon  with  air,  as  mentioned  in  the  consideration  of  general  diagnosis, 
will  obscure  a  renal  tumor  and  make  an  intestinal  one  much  more 
prominent.  Under  these  conditions,  too,  a  previous  dullness  over  the 
mass  will  be  diminished  or  disappear  if  the  mass  is  renal. 

All  tumors  about  the  sigmoid  must  be  interpreted  very  reservedly, 
both  because  of  the  frequent  accumulation  of  scybala  there  and  the 
frequency  of  perisigmoiditis.  There  is  much  more  gratification,  how- 
ever, after  recommending  an  exploratory  operation,  in  finding  a  large 
inflammatory  exudate  than  a  malignant  disease  with  glandular  or 
peritoneal  involvement,  so  that,  when  in  doubt,  our  decision  will 
always  be  to  operate  if  the  patient's  condition  permit.  There  is  so 
much  confusion  in  regard  to  the  length  of  life  if  cancer  uncontrolled  is 
allowed  to  run  its  course,  that  one  hesitates  to  state  actual  periods  of 
time.  R.  Schmidt  regards  the  duration  of  two  years  for  colon  cancer 
as  out  of  the  ordinary.  The  rectum  carcinoma  is  taken  a  little  more 
favorably,  since  Boas  and  Eichhorst  have  seen  a  duration  of  three 
years.  Others  do  not  agree  with  Schmidt's  dictum,  and  relate  in- 
stances of  colon  cancer  where  life  has  been  prolonged  four  to  six 
years  without  operation. 

Treatment. — Treatment,  if  effective,  must  always  consist  of  the 
complete  removal  of  the  growth,  but,  in  order  to  accomplish  this, 
early  diagnosis  is  even  more  important  than  in  gastric  cancer.  This, 
unfortunately,  is  rare,  and  often,  to  our  disappointment,  when  it 
seemed  as  if  the  earliest  possible  moment  had  been  taken  when  an 
opinion  in  regard  to  the  pathologic  condition  could  be  given,  the  sur- 
geon at  the  operation  has  pronounced  the  dire  words,  **  glandular  or 
peritoneal  involvement,"  and  sewed  the  patient  up  again.  Under 
three  conditions  the  operation  is  worse  than  useless:  (1)  when  age, 
marasmus,  and  the  low  hemoglobin  of  the  patient  indicate  lack  of  re- 
sisting power — they  simply  drop  out  of  existence  at  the  end  of  seven 
to  ten  days  without  any  definite  cause  where  removal  has  been  complete 
and  there  were  no  involvements;  (2)  when  metastases  and  adhesions 
can  be  detected,  which  exclude  a  radical  removal  unless,  as  in  a 
colostomy,  to  relieve  the  pain;  (3)  where  marked  ascites  indicates 
the  general  involvement  of  the  glandular  system  and  operation  does 


526  DISEASES   OF   THE   DIGESTIVE   TRACT 

not  promise  even  temporary  relief.  Such  a  condition  was  found  in 
a  case  of  ours  where,  after  the  exploratory  operation  (undertaken 
for  diagnostic  purposes),  the  persistent  ascites  never  allowed  the 
abdominal  wound  to  close.  If  ileus  accompanies  the  cancer,  a  palliative 
operation  is  much  better,  and  later,  if  desirable,  a  radical  operation 
can  be  performed.  Whether  a  complete  extirpation  is  practicable 
must  depend  always  largely  on  the  exploratory  laparotomy,  because, 
given  a  fairly  young  patient  (50  to  60  years),  with  not  too  great 
cachexia,  the  question  is  based  largely  on  adhesions  and  metastasis,  the 
degree  of  which  will  be  difficult  to  determine  without  actual  vision 
of  the  growth.  Without  the  laparotomy,  the  invasion  of  two  parts — as, 
for  instance,  the  colon  and  the  mesentery  or  the  intestine  and  the 
ovary,  or  in  all  eases  a  mass  of  glands  in  Douglas'  pouch — of  course 
indicates  at  once  the  hopelessness  of  operative  intervention.  As  a 
whole,  we  think  all  internists  are  a  little  distrustful  of  their  own 
ability  to  determine  positively  the  progress  and  extent  of  malignant  dis- 
ease of  the  abdominal  organs  without  the  aid  of  the  surgeon's  more 
intimate  touch  and  vision  of  the  organs  there,  so  that,  where  there  is 
any  indecision  in  our  own  mind,  the  laparotomy  is  recommended — not 
to  make  a  diagnosis,  against  which  some  physicians  rightfully  object, 
but  to  determine  the  extent  of  the  disease,  which  the  internist's  re- 
stricted facilities  cannot  establish.  Now,  taken  for  granted  that  the 
growth  cannot  be  successfully  removed,  whether  the  decision  be  reached 
by  the  aid  of  fingers,  eyes,  and  ears,  or  by  the  knife,  what  should  be 
done  to  aid  euthanasia?  As  pain  is  almost  always  invariably  pro- 
duced by  coarse  food  or  by  articles  producing  flatulence,  though  R. 
Schmidt  speaks  of  a  sufferer  who  was  always  relieved  for  a  time  by 
sauerkraut  (probably  on  account  of  its  laxative  effect),  we  are  to 
look  closely  after  the  diet,  and  its  choice  will  largely  depend  on 
whether  the  growth  is  in  the  large  or  small  intestine  and  the  extent  of 
the  narrowing.  If  the  growth  is  high  up  in  the  tract,  moderate 
gastric  dilatation  will  eventually  take  place,  and  the  diet  given  on 
page  331  for  gastrectasis,  following  pyloric  narrowing,  is  in  order. 
That  lower  down  the  tumor  lies,  the  greater  the  care  that  must  be  taken 
with  the  diet,  for  complete  obstruction  from  indigestible  food  is  a 
common  occurrence.  A.  Schmidt  mentions  a  fragment  of  lettuce  leaf 
which  acted  as  a  valve  at  such  a  stenosis.  Hence  all  food  must  be 
either  liquid  or  semisolid,  containing  as  little  insoluble  residue  as  pos- 
sible. Such  a  diet  has  been  given  on  page  511  for  intestinal  stenosis, 
since  that  is  the  condition  we  are  trying  to  overcome,  irrespective  of 
its  origin.     Eventually  we  will  have  periods  of  constipation  which 


MALIGNANT   GROWTHS   OF    THE   INTESTINE  527 

must  be  relieved,  for  the  accumulation  of  feces  above  the  cancer  not 
only  increases  the  pain  and  inflammation  of  the  intestine  in  the 
same  locality,  a  means  often  of  discharging  the  accumulation  by  pro- 
voking diarrhea,  but  from  supposedly  autointoxication  often  causes  a 
rise  of  temperature,  which  still  further  increases  the  wretchedness  of 
the  victim.  As  we  are  forbidden  the  use  of  cellulose,  for  reasons 
mentioned,  we  are  confined  to  fruit  juices  (orange,  grape,  lemon,  and 
apple),  to  milk  sugar  in  large  quantities,  and  the  use  of  honey  and 
molasses.  Still,  we  are  often  unable  to  overcome  the  retention,  and 
then  must  have  recourse  to  only  the  mildest  laxatives — fluid  extract 
of  cascara,  aromatic  tincture  of  rhubarb,  or  magnesium  sulphate — the 
last  preferred  by  many  on  account  of  the  extremely  liquid  stools 
produced  by  it.  Pills  must  never  be  given  on  account  of  the  possibility 
of  their  insolubility  and  obstruction  of  the  narrowed  portion.  Then, 
there  soon  comes  a  period  of  diarrhea,  which  again  taxes  our  ingenuity 
to  control.  The  stools  are  usually  putrid  smelling,  and  show  putre- 
faction rather  than  fermentation,  so  that  we  may  exclude  meat  and 
eggs  for  a  few  days  and  give  gelatine,  strained  oatmeal,  and  barley 
soups  instead.  On  the  contrary,  when  the  growth  is  situated  high  in 
the  small  intestine,  the  liquid  and  fermentative  stools,  frothy,  with 
acid  reaction,  sometimes  occur,  and  then  we  must  exclude  the  starchy 
foods — bread,  rice,  puddings,  and  potatoes — and  feed  our  patient  on 
finely  chopped  meat,  eggs,  soft  cheese,  custards,  and  gelatine.  Apart 
from  the  diet,  it  is  not  advisable  to  check  the  diarrhea  for  a  day  or 
two,  because  it  is  nature's  method  of  relieving  the  distended  intestine 
of  its  accumulation  of  feces  above  the  stricture.  When  it  threatens  to 
become  too  prostrating,  it  may  be  treated  as  ordinary  ileocolic  catarrh 
with  tannalbin,  or,  as  the  growths  are  situated  chiefly  in  the  colon,  by 
irrigation  with  dermatol  in  gum  arabic  water  (2:250).  Of  course, 
pain  will  necessarily  demand  opiates  sooner  or  later,  but  it  is  often  sur- 
prising how  long  one  can  get  along  with  substitutes  like  phenaeetin, 
codeine,  spirits  of  chloroform,  etc.,  without  the  employment  of  opium 
or  morphine.  This  applies  only  to  periods  where  there  is  a  moderately 
free  passage  through  the  stenosis.  Just  as  soon  as  a  complete  obstruc- 
tion occurs,  then  opiates  and  the  directions  for  relieving  ileus  must  be 
followed. 

POLYPI. 

Polypi,  or  adenomatous  polypi,  which  is  the  more  accurate  term, 
since  it  is  to  this  group  that  the  medical  men  refer  when  using  the 
name,  are  on  the  border  line  between  benign  and  malignant  growths; 


528  DISEASES   OF   THE   DIGESTIVE   TRACT 

in  fact,  even  when  fully  exposed  to  view  it  often  requires  an  accurate 
pathologic  examination  to  decide  this  question.  It  is  a  fact,  too,  that, 
though  they  may  exist  for  years  as  benign  growths,  eventually,  from 
constant  irritation,  they  undergo  carcinomatous  degeneration.  They 
may  be  single  or  multiple  and  grow  slowly,  even  when  the  malignant 
change  has  not  taken  place.  In  size  they  vary  from  a  pea  to  a  walnut, 
are  sometimes  pendulous,  and  then,  again,  they  may  be  seated  over 
a  fairly  large  base  with  numerous  excrescences.  In  our  cases  they 
have  always  been  found  in  the  rectum  within  reach  of  the  finger,  but 
they  may  occur  in  the  colon,  rarely  in  the  small  intestine,  and  occasion- 
ally about  the  anus.  Of  the  causation  little  is  known.  Venous  stasis 
has  been  suggested,  but,  as  they  are  found  in  children  less  than  10 
years  of  age,  congenital  influences  may  play  a  part,  and  it  has  even 
been  stated  that  they  have  been  discovered  in  different  members  of 
the  same  family.  An  explanation  of  the  malignant  degeneration  has 
been  offered  by  Hauser  in  the  additional  opportunity  extended  for  irri- 
tation by  the  polypi  floating  in  the  lumen  of  the  intestine.  This  is 
encouraged  by  the  fact  that,  when  multiple,  perhaps  only  one — ^and 
that  the  most  extensive — may  be  so  affected. 

Symptoms. — Symptoms  are  much  milder  than  those  of  annular  car- 
cinoma of  the  rectum,  though  resembling  them  in  some  ways — tenesmus 
and  bleeding  at  stool,  which  is  at  first  taken  for  hemorrhoids  until 
examination  discloses  the  small  excrescences.  In  one  of  our  cases  (a 
woman)  constant  backache  was  present,  and  the  polypus,  which  pro- 
duced tenesmus,  but  did  not  bleed,  was  discovered.  Its  removal  freed 
the  patient  from  backache,  but  the  causative  connection  between  the 
two  will  always  remain  in  doubt  in  our  mind.  Fortunately  no  malig- 
nant degeneration  had  taken  place,  though  the  surgeon  pronounced  it 
cancerous  at  its  removal ;  this  was  refuted  at  the  pathologic  examina- 
tion. When  higher  up,  these  growths  may  give  rise  to  bleeding,  with- 
out other  symptoms  or  may  produce  severe,  colon  catarrh,  with  pain, 
diarrhea,  and  the  discharge  of  much  mucus.  Patients  become  anemic 
from  the  frequent  loss  of  blood,  but,  unless  cancer  supervenes,  the 
patients  may  live  many  years.  Whenever  such  growths  are  discovered 
by  the  finger  or  rectoscope  in  the  rectum,  they  should  be  removed  as  a 
source  of  danger,  but,  if  this  is  impracticable  at  the  time,  at  least  a 
small  portion  should  always  be  removed  and  submitted  to  a  pathologist. 

Treatment. — The  treatment,  apart  from  excision,  which  is  often  im- 
practicable when  they  are  multiple,  comprises  a  diet  designed  to  allay 
the  colitis  and  irrigations  with  astringents,  of  which  dermatol  is  the 
most  satisfactory. 


CHAPTER  XXI 

NERVOUS  DISEASES  OF  THE  INTESTINE 

This  subject  comprises  those  changes  in  the  normal  motility,  secre- 
tion, and  sensibility  of  the  intestine  dependent  on  the  perverted  nerve 
innervation — at  least  in  which  no  pathological  change  in  the  intestinal 
tract  can  be  found.  As  stated,  these  cannot  be  absolutely  separated,  or 
at  least  they  run  into  each  other,  for  in  chronic  catarrh  of  the  intestine 
any  excitement  exaggerates  the  number  of  discharges,  and  a  long  con- 
tinued constipation,  due  to  nervous  origin,  may  set  up  a  colitis  from 
the  irritation  of  the  fecal  matter  on  the  mucous  membrane.  The  causa- 
tion of  this  intestinal  neurosis  is  probably  much  the  same  as  that 
given  for  the  gastric — hereditary  weakness  of  the  nervous  as  well  as 
the  muscular  system — both  contributing  to  displacements  of  certain 
divisions  of  the  intestine  if  we  are  to  believe  that  there  is  an  absolutely 
normal  site  for  every  section,  which  some  are  beginning  to  doubt;  at 
least  functional  diseases  of  the  intestine  are  rarely  found  in  well-nour- 
ished and  robust  individuals.  Then,  we  have  the  paresis  by  reflex 
action  from  other  organs,  as  from  peritonitis  or  acute  pancreatitis ;  by 
direct  influence  from  the  brain,  as  the  paralysis  following  myelitis  or 
apoplexy.  There  is,  too,  a  close  connection  between  the  neuroses  of 
the  stomach  and  intestine,  but  whether  one  is  dependent  on  the  other 
may  be  doubted.  It  is  much  more  probable  that  both  are  based  on  the 
faulty  central  nerve  innervation;  for  instance,  a  gastric  myasthenia, 
with  a  loudly  succussing  stomach,  hours  after  the  latter  should  be  free 
from  food,  will  be  associated  with  constipation.  Following  the  general 
division  of  nervous  anomalies  of  the  stomach,  we  have  those  of  the  in- 
testines, as  given  below : 

A.  Disturbances  of  motility. 

a.  Increase, 

1.  Cramp  or  spasm  of  the  intestine. 

2.  Peristaltic  unrest. 

b.  Decrease. 

1.  Paresis  and  paralysis  of  the  intestine. 

2.  Loss  of  action  of  sphincter. 

529 


530  DISEASES  OP  THE  DIGESTIVE  TRACT 

B.  Disturbances  of  secretion  in  the  intestine. 

C.  Disturbances  of  sensation. 

a.  Hyperesthesia. 

b.  Neuralgia. 

CRAMP  OR  SPASM  OF  THE  INTESTINE. 

Cramp  or  spasm  of  the  intestine  means  the  persistent  tonic  con- 
traction of  the  whole  or  a  section  of  the  tract — a  veritable  tetanus. 
Normally  this  does  not  occur,  so  that  there  must  be  some -source  of 
irritation.  Nothnagel,  by  placing  a  crystal  of  salt  on  the  peritoneal 
surface  of  the  intestine,  and  others  by  the  faradic  stimulation  of  the 
same,  have  produced  a  spasmodic  contraction,  by  which  the  section  be- 
comes bloodless  and  its  lumen  obliterated.  This  spasmodic  contrac- 
tion probably  accompanies  most,  but  not  all,  attacks  of  painful  colic, 
and  it  may  vary  in  intensity,  so  that  the  obstruction  may  be  partial 
or  complete.  From  this  category  must  be  excluded,  of  course,  those 
spasms  produced  by  ulcer  of  the  mucous  membrane,  or,  reflexly,  those 
that  often  exist  in  the  entire  tract,  when  a  portion  of  the  small 
intestine  is  pinched.  These  two  conditions  of  primary  and  secondary 
spasm  have  been  heretofore  confounded,  but  the  x-ray  has  shown  us 
that  there  may  be  long  continued  persistent  contraction  of  the  in- 
testine, sufficient  to  obliterate  its  lumen,  and  even  to  lead  to  ileus 
which  is  wholly  of  nervous  origin.  When  we  look  for  the  cause  of 
this  condition,  we  recognize  first  the  deleterious  influence  of  lead  and 
nicotine.  Lead,  in  addition  to  causing  a  moderate  contraction  of  the 
entire  intestine,  produces  an  irritation  of  the  sensible  nerves,  which 
at  times  is  exaggerated  to  a  paroxysm  of  pain.  Then  we  have  the  un- 
explainable  local  neuroses,  which  cause  contractions  of  sections  of  the 
gut,  not  always  accompanied  by  pain— sometimes  not  sudden,  but 
gradual — until  it  is  severe  enough  to  cause  ileus,  and  at  operation, 
apart  from  the  narrowed  portion  of  intestine,  not  a  vestige  of  any 
pathologic  condition  can  be  discovered  which  would  account  for  it. 
This  is  not  a  part  of  a  general  neurasthenia,  but  a  purely  local 
neurosis.  Spasms  dependent  on  tabes  and  accompanied  by  pain  are 
often  seen.  The  spasm  of  the  anal  sphincter  in  this  condition  is 
readily  detected,  and  those  of  the  colon  can  be  usually  found  if  searched 
for.  How  much  the  canoe-shaped  abdomen  and  absence  of  tympany 
in  meningitis  are  dependent  on  spasm  is  not  known,  but  at  least  it  is 
not  accompanied  by  local  pain.  These,  of  course,  would  both  be  the 
result  of  central  nervous  influence. 


NERVOUS   DISEASES   OP   THE   INTESTINE  531 

Symptoms. — The  symptoms  necessarily  vary  in  accordance  with  the 
extent  of  the  intestine  affected.  In  lead  colic  the  entire  tract  may  be 
in  a  state  of  contraction  for  days,  with  retracted  flattened  abdomen, 
while,  again,  in  a  localized  abdominal  neurosis  a  portion  of  the  small 
intestine  or  colon  may  show  a  localized  stasis  above  the  narrowing, 
and,  slowly  developing,  may  lead  to  moderate  rigidity  and  symptoms 
of  ileus  (vomiting).  Pain  usually  accompanies  the  spasm,  but  is  not 
constant  and  may  disappear,  while  the  constriction  still  persists.  It 
starts  from  some  point  in  the  abdomen  and  then  streams  over  its  en- 
tire surface.  Then,  again,  the  severity  of  the  pain  bears  no  relation 
to  the  strength  and  force  of  the  contraction.  By  palpation  little  or  no 
tenderness  can  be  elicited,  at  least  nothing  commensurate  with  the  con- 
striction, which  may  be  so  great  that  the  colon,  for  instance,  feels  like 
a  band  or  cord.  The  most  constant  and  prominent  symptom  is  the 
retention  of  flatus  and  feces;  this  is  not  absolute,  however,  and  the 
gas  passes  now  and  then  sparingly.  There  is  not  the  meteorism  com- 
mon in  organic  stenosis  of  the  intestine  and  the  ileus  usually  spon- 
taneously vanishes,  though  it  may  go  on  to  fecal  vomiting  and  an 
operation  be  necessary,  as  many  reports  in  the  literature  show.  The 
relaxation  of  the  spasm  is  always  accompanied  by  free  passage  of 
gas  and  feces.  The  general  condition  of  the  patient,  too,  is  rarely  dis- 
turbed except  from  the  pain,  the  pulse  is  not  increased,  nor  are  there 
any  evidences  of  collapse.  The  differentiation  between  spastic  and 
organic  closure  of  the  lumen  of  the  intestine  is  extremely  difficult. 
The  lessened  severity  of  the  former,  and  its  more  frequent  occurrence 
in  younger  individuals  with  unstable  nervous  equilibrium,  helps  some, 
but  one  cannot  rely  too  much  on  this  alone,  and  the  ease  must  be  as 
closely  studied  and  eared  for  as  though  we  anticipated  the  possible 
disastrous  outcome  of  true  organic  ileus. 

Treatment. — The  treatment  is  often  also  our  best  means  of  diag- 
nosis, and  the  hypodermic  injection  of  atropine  sulphate,  0.001  gram 
(Yqq  grain),  will  often  check  the  vagotonus,  commonly  regarded  as  a 
cause  of  the  spasm,  like  magic,  and  many  of  the  cures  of  organic 
stricture  reported  are  undoubtedly  of  this  character.  It  may  be  neces- 
sary to  repeat  the  dose  under  the  same  precautions  mentioned  in  true 
ileus.  The  success  of  the  treatment  is  soon  demonstrated  by  a  free 
passage  of  gas  and  feces.  In  addition  to  this,  the  hot  hip-bath  or 
electric  pad  to  the  abdomen  is  also  very  efficacious  in  relaxing  the 
spasm.  Irrigation  of  the  colon  with  a  pint  of  warm  water,  containing 
a  teaspoonful  of  spirits  of  peppermint,  also  aids.  Laxatives  had  best 
be  avoided  altogether,  for  they  increase  the  spasm. 


532  DISEASES  OP   THE   DIGESTIVE   TRACT 

PERISTALTIC  UNREST. 

Peristaltic  unrest  of  the  intestine  consists  of  a  serious  of  exag- 
gerated contractions  of  the  tract,  associated  with  a  general  neurosis, 
and  not  the  result  of  any  local  affection.  Clinically,  it  makes  itself 
manifest  by  borborygmi,  which  may  continue  for  hours.  They  are 
aroused  by  many  forms  of  mental  excitement,  such  as  entrance  into 
social  gatherings,  where  they  are  particularly  humiliating  to  the 
victim;  in  others  they  continue  for  two  or  three  hours  after  food  is 
taken,  or  after  the  use  of  cold  drinks  containing  carbon  dioxide,  as  the 
prevalent  soda  water.  Its  peculiarities  consist  chiefly  in  its  irregu- 
larity ;  it  may  cease  for  weeks  or  months,  and  then,  without  any  known 
cause,  start  in  again. 

The  patient,  when  awakened  at  night,  often  hears  these  noisy  move- 
ments of  the  bowels,  but  little  or  no  gas  is  passed  and  stool  never  fol- 
lows. The  stomach  may  be  found  also  to  participate  in  these  exagger- 
ated motions  without  producing  eructations  or  vomiting.  As  these 
motions  occur  more  often  in  persons  with  thin  abdominal  walls,  with 
diastasis  of  the  recti,  the  segments  of  intestine  can  be  distinctly  seen 
to  fill  and  collapse,  but  the  distinction  from  a  rigidity  due  to  stenosis 
is  very  marked,  since  the  former  loops  of  intestine  are  not  filled  with 
fluid  and^are  much  less  plastic.  Ordinarily  the  patients  complain  of 
no  pain,  or  at  least  only  of  a  feeling  of  mild  discomfort,  which  is  local- 
ized in  the  abdomen.  From  a  careful  study  of  these  cases  it  would 
seem  as  if  there  was  nothing  pathologic  about  these  movements,  but 
that  they  are  only  an  exaggeration  of  the  normal  physiologic 
pendulous  contractions.  Generally  only  undernourished,  hyperex- 
citable  persons  are  affected,  and  on  this  fact  one  bases  his  diagnosis 
largely,  at  the  same  time  leaving  no  stone  unturned  to  exclude  begin- 
ning stenosis  by  examination  of  patient  and  stool. 

Treatment. — The  treatment  must  be  directed  largely  to  the  pa- 
tient's general  condition,  and,  as  this  is  one  of  malnutrition  and  un- 
stable nervous  equilibrium,  we  can  only  repeat  the  course  of  extra 
meals,  cold  baths,  massage,  change  of  climate,  electricity,  etc.,  which 
has  been  advised  for  a  person  in  that  condition.  To  combat  the  local 
vagotonus  to  which  these  manifestations  are  due,  we  may  use  a  powder 
containing  extractum  belladonnae,  0.020  gram  (%  grain),  combined 
with  magnesii  oxidum  0.3  gram  (5  grains)  ;  validol  and  codeine  can  also 
be  employed  to  advantage. 


NERVOUS   DISEASES   OF   THE   INTESTINE  533 

PARESIS,  OR  PARALYSIS  OF  THE  INTESTINE. 

Paresis,  or  paralysis  of  the  intestine,  has  proved  the  bugbear  of  the 
surgeons  on  account  of  its  frequency  after  abdominal  operations — 
"postoperative  ileus,"  as  it  is  sometimes  called — but  we  must  distin- 
guish one  form,  associated  with  peritonitis,  and  a  second,  which  has 
nothing  to  do  with  infectious  complications.  The  peritonitic  form 
may  follow  all  kinds  of  abdominal  operations,  and  comes  in  the  first 
few  days.  It  is  also  seen  in  every  perforation  of  the  intestine  and  in 
sepsis  whenever  the  diaphragm  is  attacked.  When  an  ulcer  merely 
attacks  the  peritoneum,  but  does  not  break  through  it,  we  never  see 
this  paralysis,  and  even  in  typhoid  and  intestinal  tuberculosis  a  partial 
paralysis  or  paresis  with  meteorism  is  much  more  common,  undoubt- 
edly caused  by  the  peritoneal  irritation  of  an  ulcer.  Urine,  bile,  and 
blood,  when  poured  into  the  peritoneal  cavity,  produce  incomplete 
paralysis,  due  in  part  to  infectious  agencies,  but  oil  or  oxygen,  when  in- 
troduced experimentally,  will  cause  the  same  paresis,  nor  can  the  in- 
testines be  exposed  too  long  to  the  air  in  laparotomies  without  danger 
of  a  similar  effect.  The  reflex  paralyses  account  for  many  instances  of 
fatal  obstruction  after  surgical  operations  when  not  the  slightest 
vestige  of  inflammation  can  be  found.  We  have  many  examples  of 
this  following  the  tapping  of  the  hydrocele,  the  kinking  of  a  ureter  in 
a  prolapsed  kidney.  Then  there  is  occasionally  found  a  paresis  asso- 
ciated, if  not  caused,  by  gallstone  or  renal  colic,  and  possibly  other 
painful  affections  of  the  abdomen.  The  inhibitive  influence  which 
comes  from  the  brain  and  produces  intestinal  paresis  is  usually  present 
only  when  that  organ  is  suffering  from  an  attack  of  apoplexy,  but  such 
an  onset  may  also  arise  from  tabes  or  has  been  noted  in  acute  ascending 
paralysis.  Mental  depression  and  melancholia  certainly  diminish 
peristalsis,  yet  whether  they  ever  lead  to  complete  paralysis  is  un- 
known, but  hysteria  has  been  found  to  produce  so  complete  an  ileus 
that  operation  was  undertaken  for  its  relief.  Then,  at  last,  we  come 
to  the  paralysis  caused  by  strangulation.  Owing  to  the  burden  placed 
upon  the  segment  just  before  the  narrowing,  it  hypertrophies  and  over- 
comes it  for  a  certain  time,  but  at  any  moment  may  become  paralyzed, 
and  peristalsis  ceases  long  before  the  obstruction  of  the  lumen  has  be- 
come complete. 

Symptoms. — The  symptoms  of  complete  paralysis  are,  first  of  all, 
meteorism,  which  usually  involves  the  whole  tract,  but  after  surgical 
operation  may  be  confined  to  certain  segments  of  the  intestine.  The 
extent  of  this  gaseous  distention  is  governed  largely  by  the  overdevelop- 


534  DISEASES   OF   THE   DIGESTIVE   TRACT 

ment  of  the  patient's  abdominal  muscles  and  peritonitis,  both  of  which 
tend  to  restrict  the  distention,  while  it  reaches  its  greatest  extent  in 
persons  with  thin-walled  abdomens.  The  diaphragm  is  pushed  up,  and 
respiration  is  always  costal  and  shallow.  The  percussion  note  is  highly 
tympanitic,  except  over  an  occasional  filled  coil,  where  it  may  be  metal- 
lic, and,  as  soon  as  peritonitis  develops,  the  flanks  will  be  flat,  but  the 
note  will  be  hard  to  elicit  because  of  the  enormous  tympany;  the 
lumbar  region  will  give  it  best.  Ail  spontaneous  sounds  in  the  ab- 
domen have  ceased,  and  even  with  the  stethoscope  nothing  can  be 
heard.  In  this  respect  a  primary  paralysis  differs  decidedly  from  a 
primary  stenosis,  where  the  spurting  and  gurgling  sounds  are  very 
prominent.  Pain  is  practically  absent,  unless  due  to  the  primary 
disease,  as  peritonitis,  which  has  been  known  to  run  its  course  without 
pain,  but  such  a  case  is  a  rarity.  Accompanying  this  peritoneal  pain 
there  is  also  a  fully  disseminated  tenderness  of  such  a  character  that 
the  patient  cannot  endure  even  the  weight  of  the  bedclothes.  Both 
these  factors  in  regard  to  pain  militate  against  ileus  from  strangula- 
tion, for,  as  has  been  described,  tenderness  in  the  latter  is  minimal, 
and  the  pain  is  paroxysmal  and  not  constant,  as  in  peritonitis.  Dis- 
charge of  stool  and  flatus  ceases  in  paralysis,  although  one  or  two  move- 
ments at  its  beginning  have  been  known.  Introduction  of  a  colon  tube 
does  not  relieve  the  meteorism,  nor  can  enemata  wash  out  more  than  a 
few  fecal  fragments  situated  in  the  ampulla.  Vomiting  never  occurs 
until  the  cessation  of  stool  and  the  largest  degree  of  distention  has  been 
reached.  It  is  often  preceded  by  the  most  distressing  hiccoughs,  and 
the  vomitus  consists  of  the  last  liquid  food  taken,  and  rarely  of 
duodenal  contents  until  very  late.  Finally,  fecal  vomiting  sets  in,  but 
is  not  so  persistent  as  in  mechanical  obstruction,  and  also  comes  much 
later.  After  the  paralysis  is  well  established,  the  signs  of  shock, 
pinched  nose,  sunken  eyes,  livid  hands,  and  cold  sweats,  with  rapid 
pulse,  supervene,  just  as  described  under  strangulation.  We  may  have 
these  earlier,  when  the  paralysis  is  dependent  on  gallstone  or  renal 
colic,  but  there  is  an  interval  of  temporary  recovery  before  the  same 
symptoms  recur.  Associated  with  the  cessation  of  peristalsis,  tempera- 
ture and  blood  count  are  so  erratic  that  no  dependence  can  be  placed  on 
them.  Localized  peritonitic  processes  are  usually  associated  with  an 
increase  of  white  corpuscles  and  temperature,  but  general  peritonitis 
may  present  a  normal  temperature  and  a  reduction  of  the  leucocytes. 
The  urine  diminishes  rapidly  until  anuria  may  result;  the  bladder, 
too,  may  become  paralyzed  as  a  complication.  Indicanuria  is  always 
present  early,  because  of  the  relaxed  ileocecal  valve,  which  allows  the 


NERVOUS  DISEASES  OP   THE  INTESTINE  535 

putrefactive  bacteria  to  enter  the  small  intestine.  Incomplete  in- 
testinal paralysis  or  paresis  differs  from  the  complete  form  only  in 
degree.  It  never  approaches  the  state  of  collapse,  and,  if  vomiting 
occurs,  it  is  only  as  a  reflex  and  never  fecal  in  character.  Meteorism 
and  cessation  of  flatus  and  stool  may  be  equally  as  well  present,  but 
with  this  difference — while  today  the  conditions  are  most  unfavorable 
and  indicate  complete  paralysis,  during  the  night  some  gas  may  be 
passed  and  an  enema  produces  an  evacuation  of  fecal  matter,  relieving 
all  the  symptoms,  while  the  stethoscope  often  discloses  some  intestinal 
activity.  The  changing  character  of  the  severity  of  the  symptoms  and 
the  alternations  of  peristaltic  activity  and  quiescence  are  the  chief 
characteristics  of  this  form,  although  it  may  eventually  result  in  death. 
The  distinction  between  a  paralysis  from  lack  of  innervation  and  from 
a  stenosis  is  very  difficult,  and  one  in  which  time  is  the  umpire.  If 
cessation  of  stool  and  flatus  are  unaccompanied  by  spasmodic  pain  and 
rigidity  of  certain  segments  of  the  intestine,  the  former  may  be  taken 
for  granted;  if,  however,  these  symptoms  have  been  preceded  by  a 
period  of  spasmodic  pain"  and  localized  tympanites,  the  condition  may 
still  be  due  to  stenosis.  Then,  too,  when  on  the  first  or  second  day 
after  a  laparotomy  there  is  found  an  increase  of  the  pulse,  vomiting, 
meteorism,  and  rigidity  of  the  abdominal  muscles,  while  neither  gas 
nor  feces  passes,  it  does  not  take  long  to  decide  that  this  is  due  to  no 
reflex  stimulus,  but  paralysis  from  a  beginning  peritonitis.  When 
this  is  followed  further  by  rise  of  temperature,  oliguria,  fluid  in  the 
flanks,  and  signs  of  collapse,  this  opinion  is  still  more  strongly  forti- 
fied, though  peritonitis  may  exist  without  vomiting,  tenderness  of  the 
abdomen,  and  muscle  spasm.  When,  on  the  contrary,  the  first  few 
days  elapse  without  significance,  and  then  there  is  absence  of  stool  and 
no  passage  of  flatus,  moderate  distention  coming  on  slowly,  but  no 
tenderness  or  spasm  of  the  abdominal  muscles — while  the  temperature 
remains  normal  and  the  general  condition  good — we  must  look  else- 
where than  to  peritonitis  for  the  cause  of  our  paresis.  In  other  words, 
as  stated,  it  is  the  time  and  rapidity  of  the  development  of  symptoms 
on  which  we  base  our  opinion. 

Treatment. — The  treatment  can  be  said  to  be  wholly  surgical  when 
peritoneal  complications  are  present,  for,  whatever  may  be  thought 
in  regard  to  physical  or  medicinal  means  in  obstruction  from  obtura- 
tion and  stenosis,  there  can  be  no  question  that,  once  the  diagnosis  of 
intestinal  paralysis  accompanied  by  peritonitis  is  assured,  its  victim  is 
the  subject  of  a  surgeon's  efforts.  The  surgical  means  of  relief  will 
not  be  discussed  here,  but  many  surgeons  attempt  to  prevent  such  a 


536  DISEASES  OP  THE  DIGESTIVE  TRACT 

complication  by  a  hypodermic  injection  of  physostigmine  salicylate  in 
doses  of  0.0005  gram  (M20  ^rain),  but  it  has  always  seemed  to  us  that 
ether  was  not  wholly  an  unmixed  blessing,  since  it  allows  the  surgeon 
to  unnecessarily  manipulate  the  abdominal  organs  and  removes  the 
need  of  rapidity ;  hence  greater  speed  and  less  handling  of  the  organs 
would  seem  the  greatest  prophylactic.  When,  on  the  contrary,  there 
are  no  peritoneal  complications,  we  may  safely  make  use  of  medicinal 
means  to  overcome  the  paresis,  and,  curiously  enough,  atropine,  which 
we  employ  to  stop  spasm,  in  larger  doses  stimulates  peristalsis  and  can 
be  given  hypodermically  in  these  eases  in  doses  of  0.003-0.005  gram 
(^0-/42  grain).  As  we  have  a  natural  fear  of  such  large  doses  on 
account  of  the  almost  certain  occurrence  of  toxic  symptoms  (dry 
throat,  dilated  pupils,  and  great  mental  excitement),  we  may  inject 
0.001  gram  (%o  grain)  at  three-hour  intervals  until  the  maximum  of  5 
mgms.  is  reached ;  if  successful,  the  passage  of  gas  and  stool  begins  al- 
most at  once.  Physostigmine  salicylate  may  also  be  used  for  overcom- 
ing a  paresis  unaccompanied  by  peritonitis  as  well  as  for  prophylactic 
purposes,  but  only  where  it  is  certain  that  no  stenosis  exists.  Irriga- 
tions with  a  colon  tube  may  be  tried,  either  alone  or  in  conjunction 
with  the  faradic  current,  which  has  its  advocates.  There  is  not  the 
slightest  doubt  that  it  will  produce  powerful  contractions  of  the 
sphincter,  but  its  action  on  the  intestine  above  is  somewhat  in  doubt. 
When  vomiting  begins,  gastric  lavage  should  be  employed  at  frequent 
intervals,  which  has  the  power  of  stimulating  intestinal  peristalsis  in 
the  same  way  that  colon  irrigation  does.  When  the  symptoms  of  col- 
lapse come  on,  camphor  in  oil  as  prepared  in  ampules,  or  strophanthin 
in  0.0005-grara  (^20-§^i*ain)  doses,  should  be  injected  with  a  hypo- 
dermic syringe.  Hormonal  still  remains  an  effective  (if  used  intra- 
venously), but  dangerous,  remedy,  and  should  be  employed  as  metallic 
mercury  was  in  the  old  times  for  the  same  purpose — only  as  a  last 
resort.  That  most  distressing  symptom — thirst — cannot  be  gratified 
by  unlimited  amounts  of  water,  because  each  glass  is  usually  followed 
by  vomiting,  which  exhausts  the  patient,  but  must  be  combated  with 
lumps  of  ice  or  small  quantities  of  champagne. 

LOSS  OF  ACTION  OF  THE  SPHINCTER. 

Loss  of  action  of  the  sphincter  is  chiefly  found  in  disease  of  the  cord 
(tabes  and  myelitis),  chronic  dysentery,  proctitis,  and  particularly 
prolapse  of  the  rectum  may  cause  an  open  anus.  Men  with  urethral 
strictures  and  women  with  perinea  torn  at  labor,  including  probably 


NERVOUS   DISEASES   OF    THE   INTESTINE  537 

some  of  the  anal  muscles,  both  often  have  an  uncontrollable  sphincter. 
There  are  all  degrees  of  this  weakness.  Many  have  control  when  the 
stool  is  formed,  but  lose  it  as  soon  as  it  becomes  liquid.  Any  sudden 
motion — sneezing,  coughing,  laughing,  or  raising  an  object — causes  the 
involuntary  discharge  of  flatus  and  often  of  feces.  In  the  various 
forms  of  paralysis  of  the  sphincter  from  disease  of  the  spinal  cord,  the 
patient  has  no  knowledge  of  the  act  of  defecation,  which  is  not  con- 
tinuous unless  the  feces  are  liquid,  but  occurs  as  often  as  the  ampulla 
fills.  In  these  cases,  too,  three  or  four  fingers  may  be  introduced 
through  the  anal  opening  without  any  resistance.  Ordinarily  there  is 
also  loss  of  the  vesical  sphincter,  so  that  both  urine  and  feces  are  passed 
unconsciously. 

Treatment. — The  treatment  comprises  repair  of  a  torn  perineum  or 
a  divulsion  of  a  stricture,  if  either  exists.  Local  treatment  of  a  proc- 
titis with  dermatol  and  a  powder  blower  will  help  that  variety,  but  for 
those  arising  from  disease  of  the  cord  but  little  can  be  done,  except  to 
arrange  the  diet  so  that  the  stool  shall  always  be  formed,  by  eliminating 
fruit,  green  vegetables,  and  sweets.  The  employment  of  a  faradic  cur- 
rent with  a  rectal  electrode  and  a  broad  pad  upon  the  abdomen,  in  con- 
junction with  the  use  of  rectal  suppositories,  twice  daily,  of  strychnine 
sulphate  0.010  gram  (^(j  grain),  may  be  tried,  without  much  expecta- 
tion of  any  more  than  temporary  relief. 

DISTURBANCES  OF  SECRETION. 

Disturbances  of  secretion  manifest  themselves  in  two  forms — nervous 
diarrhea,  which  is  undoubtedly  due  to  a  primary  hypersecretion  of 
intestinal  fluid,  and  is  considered  under  the  functional  disturbances 
(page  428),  and  mucous  colitis,  where  the  discharge  of  pure  mucus 
without  fecal  matter  has  been  regarded  by  some  authorities  as  of  purely 
nervous  origin,  and  by  others  as  being  an  outcome  of  a  low  grade  of 
colon  catarrh.  This,  too,  is  discussed  on  page  461  under  chronic 
mucous  colitis. 

DISTURBANCES  OF  SENSATION. 

Disturbances  of  sensation  experienced  in  the  abdomen  without  any 
gross  pathologic  change  are  rare,  but  still  they  do  undoubtedly  exist. 
It  is  safer  always  to  consider  that  there  is  a  cause  which  we  cannot 
find  than  to  too  easily  ascribe  all  pains  in  this  region  to  neuralgia. 
There  are,  for  instance,  chronic  appendicitis  and  duodenal  ulcer,  ad- 


538  DISEASES   OF   THE   DIGESTIVE    TRACT 

hesions,  following  all  forms  of  operative  intervention,  or  spontaneous 
disease,  which  cause  pain  when  different  parts  of  the  tract  are  over- 
filled with  liquid  or  gaseous  contents.  Then  there  are  diseases  of  the 
kidney,  gallbladder,  or  female  genitals,  the  pain  of  which  may  be 
carelessly  attributed  to  intestinal  neuralgia  or  gastralgia  without  a 
more  careful  investigation,  not  to  speak  of  myalgia  of  the  abdominal 
walls,  to  which  A.  Schmidt  has  called  attention. 

INTESTINAL  HYPERESTHESIA. 

Intestinal  hyperesthesia  applies  to  those  disagreeable,  unpleasant 
sensations  localized  in  the  abdomen  and  described  as  "fullness," 
' '  burning, "  "  tearing, ' '  and  ' '  stabbing, ' '  but  rarely  approaching  actual 
pain.  They  usually  occur  at  a  definite  period  after  food  is  taken,  but 
may  equally  as  well  come  after  excitement,  muscular  strain,  or  fol- 
low no  law  whatever.  Several  patients  of  ours  were  awakened  early 
in  the  morning  by  these  sensations,  which  were  ascribed,  as  they  often 
are,  to  gas,  but  laxatives,  carminatives,  and  enemata,  taken  as  soon 
as  the  former  were  felt,  failed  to  produce  any  effect.  The  individuals 
were  otherwise  in  excellent  health,  and  some  reported  that  while  on 
vacations  these  dolorous  sensations  disappeared.  They  may  be  expe- 
rienced over  the  whole  abdomen  or  in  localized  sections,  of  which  the 
ileocecal  region  is  the  most  common,  the  sigmoid  next,  and  finally  the 
rectum  and  anus,  particularly  the  last  when  there  is  coincident  sexual 
neurasthenia.  ]\Iany  of  the  sufferers  from  these  sensations  belong  to 
the  great  group  of  neurasthenics  and  hypochondriacs,  and  have  the 
most  persistent  fixed  ideas.  Many  feel  assured  that  they  have  an  in- 
flamed appendix  and  demand  operation.  Another  patient  declared 
that  he  had  a  stricture  of  the  intestine,  and  was  positive  he  could  point 
out  the  very  spot  where  it  was  situated.  Before  he  came  under  our 
care  a  surgeon  had  opened  his  abdomen  twice  without  finding  the 
stricture,  but  the  patient's  conviction  of  his  condition  was  just  as 
strong.  Another  powerful,  absolutely  healthy  business  man,  somewhat 
overworked,  insisted  he  had  a  cancer  of  the  intestine,  though  his  dis- 
comfort never  approached  actual  pain  and  he  had  never  lost  a  pound 
of  flesh.  It  has  been  our  experience  that  such  patients  stick 
tenaciously  to  their  preconceived  ideas  and  put  but  little  reliance  on  a 
physician's  physical  examination.  The  x-ray,  however,  impresses 
them,  and,  if  that  shows  conditions  to  be  perfectly  normal  in  the  tract, 
that  fixed  idea  at  least  is  removed,  perhaps  to  be  replaced  by  another. 

Treatment. — The  treatment  must  be  directed  to  the  general  eondi- 


NERVOUS   DISEASES   OF    THE   INTESTINE  539 

tion,  based  on  hygienic  principles,  for  the  more  it  is  directed  to  the 
intestinal  tract  the  more  irrational  becomes  the  patient,  until  every 
act  of  his  life  is  considered  only  from  the  standpoint  of  what  effect  it 
will  have  on  his  abdomen.  Before  the  present  method  of  x-ray  work 
on  the  intestinal  tract  was  attained,  some  of  our  patients  were  oper- 
ated for  suspected  extensive  adhesions,  which  could  not  be  absolutely 
verified  by  physical  examination.  Rarely  minor  bands  were  found  and 
separated,  but  the  mental  condition  was  never  improved  by  such  ef- 
forts, and  usually,  after  a  return  from  the  hospital,  the  patient  com- 
plained as  bitterly  as  before  of  his  disagreeable  abdominal  sensations. 

INTESTINAL  NEURALGIA. 

Intestinal  neuralgia  differs  from  the  preceding  by  either  exacerba- 
tions of  the  dolorous  sensations,  at  intervals,  to  actual  excruciating 
pain,  resembling  spasmodic  colic,  or  the  attacks  may  spring  up  unex- 
pectedly after  a  period  of  absolute  well-being.  The  distinction  from 
the  spasm  associated  with  stenosis  or  membranous  colitis  can  be  made 
only  after  close  observation  and  examination  of  the  stool.  Enteralgia 
from  plumbism  is  not  always  associated  with  retracted  abdomen  and 
obliteration  of  the  lumen  of  the  intestine  from  spasm,  nor  is  the  re- 
tention of  the  feces  more  than  a  temporary  affair.  In  other  words, 
lead  colic  may  exist  as  a  purely  sensory  disturbance,  and  is  not  neces- 
sarily confined  to  paroxysms,  but  may  be  constant,  only  of  a  lesser  de- 
gree. It  has  been  experimentally  proven  on  animals  that  the  seat  of 
the  pathologic  change  in  this  form  is  the  great  abdominal  ganglion, 
and  the  results  of  some  autopsies  on  persons  dying  from  chronic  lead 
poisoning  have  shown  similar  changes,  but  it  has  not  by  any  means 
been  proven  that  these  always  exist. 

With  the  spasmodic  enteralgia  of  tabes,  which  belongs  to  this  class, 
however,  the  seat  of  the  pathologic  process  is  situated  in  the  posterior 
roots  of  the  spinal  cord.  Why  these  attacks  occur,  no  one  has  been  able 
to  determine,  and,  according  to  A.  Schmidt,  they  are  sometimes  accom- 
panied by  an  excessive  secretion  of  mucus,  and,  as  already  stated,  occa- 
sionally with  spasm.  The  gout  of  the  abdomen,  attacks  of  enteralgia 
due  to  the  over-accumulation  of  uric  acid  in  the  system,  described  by 
the  English,  probably  has  no  existence.  Outside  of  the  varieties  men- 
tioned, there  is  probably  no  true  enteralgia.  The  spontaneous  idio- 
pathic form,  sometimes  described,  apparently  does  not  exist,  and 
nothing  can  be  more  unsafe  than  to  attribute  sharp  attacks  of  ab- 
dominal pain  to  enteralgia.     The  forms  which  occur  after  operation 


540  DISEASES  OF   THE  DIGESTIVE   TRACT 

are  unquestionably  dependent  on  adhesions  or  from  sear  tissue,  involv- 
ing the  nerve  endings,  and  not  from  the  original  disease  for  which  the 
operation  was  undertaken,  as  claimed  by  some — a  predilection  of  that 
part  toward  pain.  Very  often  manipulations  of  the  part  under  the 
fluoroscope  screen  will  easily  clear  up  the  diagnosis.  So  frequently 
are  these  indistinct  enteralgias  confused  with  myalgias  of  the  ab- 
dominal muscles,  especially  when  the  pain  is  increased  by  a  long 
breath,  bending,  coughing,  or  sneezing,  that  a  course  of  aspirin  or  some 
other  anodyne  is  always  advisable  for  diagnostic  purposes. 

Treatment. — The  treatment  is  necessarily  directed  toward  the  cause 
of  the  attacks — lead  poisoning  or  sclerosis  of  the  cord.  Of  course  the 
pain  must  be  immediately  relieved  by  a  hypodermic  of  morphine,  with 
hot  applications  to  the  abdomen,  but  from  that  point  the  ways  sepa- 
rate. If  the  sclerosis  arises  from  syphilis,  specific  treatment  may  be 
employed,  including  the  newer  salvarsan,  but  in  our  experience  noth- 
ing has  been  able  to  check  the  attacks  of  pain  until  the  disease  is  well 
advanced  and  marked  paralytic  symptoms  appear,  when  they  cease 
spontaneously.  With  the  lead  poisoning  the  outlook  is  brighter,  and  a 
free  use  of  the  iodides  as  well  as  a  morning  dose  of  magnesium  sulphate 
usually  checks  the  attacks.  Those  due  to  adhesions  are  also  equally 
as  discouraging,  because,  when  freed  by  operation,  they  are  apt  to  re- 
form. In  one  case  where  the  abdomen  had  been  opened  once  to  free 
adhesions  and  the  pain  returned,  fibrolysin  (thiosinamine  and  sodium 
salicylate)  was  injected,  the  contents  of  an  ampule  every  other  day, 
with  relief,  but  whether  it  acted  as  an  anesthetic  or  freed  the  adhesions 
was  a  doubtful  matter;  at  least  its  general  use  for  that  purpose  does 
not  always  produce  such  favorable  results. 


INDEX 


Abdomen, 

ascites  of,  60 

canoe  shape,  78 

inspection  of,  73 

partial  enlargement,  causes  of,   75 

percussion  of,  93 

prominent,  causes  of,  74 
Abdominal  aorta, 

position  of,  28 

sclerosis  of,  496 

sensible  pulsations  of,  60 

tenderness  of,  82 
Abdominal  belts  or  bands,  359 
Abdominal   muscles,    tenderness   of,    80 
Abdominal    organs,    normal,    palpation 

of,  86 
Abdominal   walls,   influence  of  respira- 
tion,  74 
Abscess,   183 

appendical,  341 

subphrenic,  341 

periproctitic,  475 

perisigmoiditic,  472 
Absorption, 

in  stomach,  36 

intestinal,   43 
Achroodextrin,   30 
Achylia  gastrica,  36,  46,   145,  173,  372 

forms  of,  375 

gastric  content   in,   374 

symptoms  of,  373 

treatment  of,   375 
Acliylia  pancreatica,  434 

influence  of,  55 

with  achylia  gastrica,  373 
Acid,  carbolic,  479 
Acids,   total, 

significance  of,   151 
quantitative  estimation  of,   150 
Acidol,   263 
Adrenalin,  312,  495 
Aerophagy,  63,  379 
Agar-agar  and  regulin,  272 
Age  and  sex,  48 
Alcohol,  205,  481 
Alkalies,  medicinal  use  of,  263 
Albuminuria,  in  gastric  diseases,  52 
Aloin,  185,  271 
Amidulin,  30 
Amino-acids,  41 

action  on  acid  in  gastric  cancer,  148 

test  for,  in  gastric  cancer,  157 
Anacidity, 

in  gastric  cancer,  148 

in  gastric  diseases,   152 

in   other  diseases,   148 
Anemia,   pernicious, 

association    with    intestinal    para- 
sites, 423 


541 


Anemia. — Continued. 

cause  of  achylia  gastrica,  373 
confusion  with  gastric  cancer,  343 
influence  of,  54 
Anesthesin,  429,  494 
Aneurism,  efl^ect  of,  52 
Ankylostoma      duodenale,      hookworm, 
191,  425 
egg  of,   193 
treatment  of,  426 
Anorexia,  nervous, 
symptoms  of,  390 
treatment  of,  391 
Antiperistalsis,   33 

in  pyloric  stenosis,  327 
Antrum,  control  of  by  sensations,   34 
Apomorphine  hydrochloride,  296 
Appendicitis,  52,  126,  448 
hematemesis  with,  285 
indican  with,   178 
indications   for   surgery,   285 
periodicity  of,  50 
surgery  of,  284 
Appendicitis,   acute, 
causation  of,  449 
leucocytes  in,  452 
localized  tenderness,  451 
surgical  treatment  of,  455 
Appendicitis,   acute, 

symptoms  of,  450 
Appendicitis,  acute  and  chronic, 
diagnosis  of,  454 
medicinal  treatment  of,  454 
Appendicitis,   chronic   or   recurrent, 
action   on  gastric  secretion,   55 
causes  of,  452 
influence  of,  52 
surgical  treatment  of,  456 
symptoms   of,   453 
Appendix,  position  of,  22 
Appetite,  55 

affected  by  chlorosis,  56 
Argyria,   320 
Aristol,    479 
Arteries,   26 
gastric,  26 

mesenteric,     infarcts,     treatment    of, 
501 
symptoms  of   thrombosis,   500 
thrombosis  of,  499 
right  common  iliac,  26 
superior  mesenteric,  26 
Arteriosclerosis, 

alleged  cause  of.  45 
confusion  with  gastralgia,  393 
intestinal,  diagnosis  of,  497 
symptoms  of,  497 
treatment  of,   498 
Ascaris  lumbricoides,  round  worm,  191 
Aspidium,  423 


542 


INDEX 


Aspiration  bulbs,  133 

Aspirin,  334 

Asthenia  universalis  congenita,  49,  73, 

325 
Atony,  gastric,  353 
Atony,  secondary,  326 
Atropine,   methyl-nitrate,   269 

methyl-bromide,  371 
Atropine  sulphate,  269,  513,  536 
Auscultation,  100 

of  lower  border  of  stomach,  103 
Autointoxication,  408 

antidotes,  to,  45 


B 


Bacilli,  lactic  acid,  157 

"thread"-like   or   Boas-Oppler, 
in  gastric  content,  162 
in  feces,  186 
significance  of,   163 
Bacillus  coli  communis,  44 
Bacteria,  in  gastric  content,  162 
Basedow's  disease,  influence  of,  54,  426 
Beef  tea,  211 
Beer,  206 

Belladonna,  269,  512 
Benzidine,   185 

Beverages,  alcoholic  content  of,  207 
Bile, 

amount  of,  42 

control  of,  41 

in  gastric  content,  143 

in  vomitus,  68 
Bishop's  cap,  radiogram  of,   114 
Bismuth  meal,   106 

salts,  274 

subgallate,  527 
Bitters,  medicinal  use  of,  265 
Blood, 

examination  and  significance  of,  54 

in  gastric  content,   143 

in  vomitus,  68 
Blood   pressure,   increase   of,   496 
Borborygmi,  60 

Bowel  movements,   significance  of,   69 
Bread,  217 

Graham,   218 
Breath,  foul,  significance  of,  69 
Bulimia, 

symptoms  of,  389 

treatment  of,  389 
Burns,   481 
Buttermilk,  202 


Calcium  chloride,  312,  495 

Calomel.   272 

Camphor,  536 

Cancer,  heredity  of,  49 

Cancer,  colon, 

complications   of,    523 
radiogram  of,  521,  522 


Cancer. — Continued. 

stools  in,  519 

surgery   of,  286 

symptoms  of,  518 

tumor  in,  520 
Cancer,  duodenal, 

gastric  content  in,  523 

infrequency   of,   523 
Cancer,  gall  bladder,  343 
Cancer,   gastric, 

appetite  in,  339 

at  cardia,  343 

cachexia   in,    341 

character   of  stools,   340 

diagnosis  of,  341 

differentiation       from      pernicious 
anemia,  343 

duration  of,  335 

early  symptoms  of,  336 

edema  in,  341 

eructations  in,  337 

invasion  of  liver,  341 

medicinal   treatment   of,    345 

metastasis,   91,   340 

pain  of,  338 

radiogram   of,    125 

radiographic    appearance    of,    111 

results  of  surgical   treatment,  281 

subphrenic   abscess   in,    341 

surgical  treatment  of,   281 

tongue  in,  340 

treatment  of,  343 
Cancer,  ileal,  524 
Cancer,   intestinal, 

diagnosis  of,  524 

medicinal   treatment   of,   527 

palliative  operation   for,   526 

treatment  of,  525 
Cancer,  of  liver,  523 
Cancer,  rectal,  517 

Kraske  operation  for,  288,  518 

odor  of,  518 

radiogram  of,   119 

rectoscope,  use  of,  518 
Cancer,  rectal, 

stools  in,  517 

surgery  of,  287 
Cardia,   position  of,   18 
Cardia,  relaxed,  treatment  of,  388 
Cardiac  failure, 

as  cause  of  gastric  catarrh,  298 

influence   on   appetite,   56 
Cardialgia,  nervous, 

causes  of,  392 

treatment  of,  393 
Cardiospasm,   275,   376 

diflferentiation   from  cancer,   377 
treatment  of,   377 
Cascara     sagrada      (rhamnus     parashi- 

ana) ,  271 
Casein,   212 
Castor  oil,  271 
Catarrh, 

gastric,   46,  295,   298 


INDEX 


543 


Catarrh . — Continu  ed. 
intestinal,   49,   429 
of  bile  ducts,  441 
Cecum,      tuberculous,      radiogram      of, 

116 
Cecum  mobile,   126,   355 

operation  for,  286 
Cellulose, 

action  of,  in  intestine,  45 
digestion  of,  216 
Cereals,   216 
Champagne,  206 
Cheese,  214 
Chloroform,  527 

Chlorosis,   association  with  gastric  ul- 
cer, 306 
influences  of,   53 
nausea,  caused  by,  61 
Chlorophvl,    measurement    of   motility, 

139 
Cholangitis,  441 
Cholecystitis, 

action   on   stomach,  46,  63 
pain  of,  58 
Cholelithiasis, 

cause  of  pressure,  57 
confounded  with  gastric  ulcer,  308 
lumbar  area  of  tenderness,  84 
periodicity  of,  50 
reflex  action  of,  55 
surgery  of,  290 
Chrysarobin,   494 
Cirrhosis,   hepatic,   491 
influence  of,  52 
influence  on  appetite,  56 
Clostridium  butyricum,   186 
Cocaine,  495 

Cocoa  and  chocolate,   204 
Colalin,  420 
Colic, 

gallstone,  51,  59,  64 
pancreatic,  392 
renal,   59,  64 
Colitis,  457 
Colitis,  polypi  in,  458 
Colitis,  acute, 

diagnosis  of,  460 
dietetic  treatment  of,  461 
feces  in,  459 
leucocytes  in,  459 
symptoms  in,  458 
treatment  of,  460 
Colitis,   chronic, 

association     with     disease    of    the 

genital   organs,   462 
diagnosis  of,  465 
fecal  mucus  in,  461 
intestinal  gravel   in.  462 
mucous  and  membranous,  461 
stools  in,  464 
symptoms  of,  463 
treatment  of,  466 
use  of  the  rectoscope  in,  464 
Colitis,    ulcerative    (dysentery),   467 


Colitis. — Continued. 

complications  of,  469 
diagnosis  of,  469 
feces  in,  468 

medicinal  treatment  of,  470 
rectoscopic     application     of     pow- 
ders,  470 
Colitis,   ulcerative, 

surgical  treatment  of,  470 
symptoms  of,  468 
treatment  of,  469 
Colitis  ulcerosa,   surgery   of,   288 
Colon, 

abnormalities  of,  23 
adhesions,  radiogram  of,   120 
bacterial  action  in,  43 
cancer,  radiogram  of,  117 
normal   position  of,  22 
painful   peristalsis  of,  60 
palpation  of,  86 
powers  of  elimination,  45 
radiogi'am  of,   114 
spasm  of,   87 
stenosis  of,  126 
W-shape,  25 
Coloptosis,   127,  354 
symptoms  of,  355 
Condiments,  222 

use  of,   197 
Condurango,  266,  304 
Congo  red  paper,  147 
Constipation, 
effect  of,  49 
influence  on  breath,  70 
atonic  and  spasmodic,  406 
Constipation,    habitual   functional,   406 
association    with    albuminuria,    414 
cardiac    irregularities,    414 
colon  catarrh,  414 
hypersecretion,  410 
causation  of,  407,  409 
diagnosis  of,  415 
hemorrhoids  in,  408,  413 
medicinal   treatment   of,   418 
occlusion  from,  421 
operative  intervention  in,  421 
physical  treatment  of,  417 
relation  to  cellulose  digestion,  410 
stools  in,  409,  413 
symptoms  of,  408 
treatment  of,  415,  417 
treatment  by  enemata,  420 
x-ray  examination  of,  411,  412 
Cramp,  intestinal,  ' 

from  vagatonus,  531 
stomachic,  392  '  ' 

symptoms  of,  531  ' 

treatment  of,  531 
Creasote,   266  : 

Crises,  gastric, 

in   diabetes,   59 
in  neuroses,  58 
pain   of,  392 
periodicity  of,  50 


544 


INDEX 


Crises. — Continued. 
surgery  of,  280 
vomiting  of,  64,  381 
Currants,  raisins  and  prunes,  diagnos- 
tic uses  of,   138 
Cystitis,   522 
action  of,  52 


D 


Defecation,  38 
Deglutition,   30 

normal  sounds  of,  101 
sounds  of,  31 
Dermatol,  527 
Diabetes, 

cause   of  bulimia,  389 
gastritis,  caused  by,  399 
influence  of,  54 
thirst,  56 
Diaphragm,   74,  90 
Diarrhea,  nervous,  428 
feces  in,  429 
treatment  of,  429 
Diastasis,  of  recti,  78 
Diet,   lacto-vegetable,   228 

liquid,  cause  of  coated  tongue,  73 
milk,  226 
salt-free,  228 
salt-free,  table  of,  229 
vegetarian,  227 
Dietetics, 

in  digestive  disorders,   195 
individual  idiosyncrasies,   196 
prophylaxis,   196 
Diet  List, 

for   cancer,   gastric,   344 

for  constipation,  416 

for   dilatation   of   the   stomach   with 

anacidity,  331 
for   dilatation   of   the   stomach   with 

hypersecretion,  331 
for  enterocolitis,  acute,  437 
for  enterocolitis,   chronic,  439 
for  gastric  ulcer,  315 
for     gastric     ulcer,     chronic      (Len- 

hartz),  317 
for   gastritis,   chronic,   302 
for  hypersecretion,  370 
for     intestinal     indigestion,     fermen- 
tative, 405 
for   intestinal   stenosis,   511- 
for  malnutrition,  225 
for  myasthenia  gastrica,  386 
for    myasthenia   gastrica,    with    con- 
stipation, 386 
Digestion,     continuous     and     intermit- 
tent, 361 
gastric,  31 
intestinal,  37 
oral,  29 
salivary,  32 

salivarv  prolongation  of  in  stomach, 
32 


Dilatation  of  stomach,  324 
causes,  326 
treatment  of,  329 
Diuretin,  498 
Diverticulum,   of   colon,   operation   for, 

289 
Douglas'  pouch,  92 

metastases    in,    from   gastric    cancer, 
340 
Duodenum,  position  of,  22 
Dvsphagia    (difBcuItv   in    swallowing), 
62 
from  true  spasmodic  stenosis,  62 
from    malignant    disease    of    esopha- 
gus, 102,  343 
Dyspnea,    174,   300 

contraindication  to  use  of  tube,   135 


E 


Ectasia,  atonic,  325 

form  of  stomach,  109 
Effervescent  mixture,  94 
Eggs,  208 
Electric  pad,  232 
Electrode, 

intragastric,  248 

rectal,   250 

Wegele's,  249 
Emaciation,  interpretation  of,  54 

of  mesenteric  arteries,  499 
Embolism,  pulmonary,  499 
Embolus,  26 
Emphysema,  as  cause  of  gastritis,  298 

as  cause  of  venous  hyperemia,  490 

influence  of,  53 
Empyema,  of  gall  bladder,  500 
Endo'carditis,   480,   499 
Enemata,  nutrient,  259 

formulas  for,  261 
Enteritis,  441 

stools  in,  442 

treatment  of,  442 
Enterolith,  413 

cause  of  occlusion,   508 
Enterocolitis,  434 

diagnosis  of,   436 

acute,   stools  in,   435 

acute,  treatment  of,  436 

chronic,  medicinal  treatment  of,  440 

chronic,  treatment  of,  438 
Eosinophilia,   significance  of,    187 
Epigastric  murmurs,   105 

of  gastric  cancer,  339 
Epigastric  pressure   point,   81 
Epithelium,  gastric,    161 
Erosion,   liemorrhagic.    145,   300 
Eructations    (belching),  62 

acid,  61 

bad  smelling,  62,  327 

bitter.   327 

nervous,   63,  379 
Eructatio  nervosa,  63,  379 

symptoms  of,  380 


INDEX 


545 


Eructatio  nervosa. — Continued. 
treatment  of,  380 

Erythrocytes,   in   gastric  content,   162 

Erythrodextrin,  30 

Esophageal    stricture,   sounds   in,    101 

Esophagus,   foreign   bodies  in,  276 
malignant  growth  of,  277 
stenosis  of,  with  radiogram,   121 

Ethereal  sulphates,  45,   178 

Eumydrine,   269 

Examination,  rectoscopic,   127 

Exner  needle  reflex,  38 


Fat,  in  gastric  content.  161 
Fats,  213 

Fatty  acids,  detection  of,   157 
Feces,  bacteria  of,   186 

bacterial   content   of,  44 

color   of,    167,    170 

connective  tissue  in,  46,   172 

constituents  of,   166 

daily  amount  of,   169 

fasting  constituents  of,  45 

fatty  acid  needles  in,   175 

fermentation  of,  177 

indol  and  skatol  in,  177 

intestinal  parasites  in,  186 

microscopic  examination  of,   174 

occult  blood  in,   184 

odor  of,   171 

protozoa  of,  186 

pus  in,  182 

reaction  of,   168,   177 

sarcinae  in,  342 

significance  of  soap  crystals,   176 

stercobilin   in,   178 

trypsin  in,   174 

visible  fragments  in,   172 
Fermentation,  products  of,  44 
Ferments,  detection  of,  154 

fat  splitting,  41,   156 
Fetor  ex  ore,  69,  299 
Fever,  of  acute  gastritis,  276 

of  appendicitis,  450,  455 

of  colitis,  458 

of  dysentery,  468 

of  enterocolitis,  436 

of  gastroenteritis,  431 

of   perisigmoiditis,   471 

of  typhlitis,  446 

of   typhoid,   64 

differentiation    from    enterocolitis, 
436 
Fibrolysin,  540 
Filmaron,  424 
Fish,   211 

Fissures,  anal,  479 
Fistula, 

anal,  478 

operative  treatment  of,  291 
tuberculous,  489 


Fixation,  of  normal  gastric  parts,  86 

of  tumors,  90 
Flatulence,   69 
Foods,  breakfast,  216 
Foods,  caloric  value  of,  208 

carbohydrate-containing,   215 

character  of,   199 

fatty,  215 

iron-containing,  216 

liquid,  200 

constituents  of,  207 

predigested,   212 

temperature  of,   198 

time  of   leaving  stomach,   33 

unsuitable,   54 
Food  fragments,  significance  of,   144 
Friction  rub,  105 
Fruits,  220 
Fruit  juice,  206 


G 


Gall  bladder,  position  of,  22 

Gall    stones,    cause    of    occlusion,    508, 

514 
Gases,  absorption  of,  44 
Gastric   bismuth  residue,  form  of,   108 
Gastric   content, 

abnormal  elimination,    143 

amount  of  in  fasting  stomach,  141 

chemical  examination  of,    146 

color  of,   143 

dry  and  liquid  meals,  141 

estimated  amount  of,  140 

expression  of,   130 

green  color  of,   143 

in  achylia,   142 

macroscopic   examination   of,   139 

microscopic   examination    of,    160 

microscopic      examination      of      food 
remnants,  161 

mucus  in,   143 

normal  acid  limits  of,   151 

normal  amount  of,   140 

odor   of,    142 

plant  fibers  in,   161 

significance  of   residue,    141 

stage  of  starch  digestion,   142 

starch   granules   in,    160 

state  of  digestion,   142 

three  layer  formation,   142 

tissue   fragments   in,    144 

yeast  fungi  in,   142,   164 
Gastric  juice, 

amount  of,  35 

deficient  secretion,    152 

increased  secretion  of,   152 

mental  control  of,  34 
Gastritis,   acute, 
causes   of,    295 
diet  in,   297 
symptoms  of,  295 
treatment  of,  296 


546 


INDEX 


Gastritis,    chronic, 
causes  of,   298 
diet   in,  301 
symptoms  of,  299 
treatment  of,  301 
Gastritis  phlegmonous,   298 
Gastroenteritis,   431 

stools  in,  433 

symptoms  of,  432 
Gastroenterostomy, 

determination  by  radiogram,   113 

for  gastric  dilatation,  334 

indications  for,  278 

results  of,  278 
Gastrodiaphane,   106 
Gastrojejunostomy,  277 
Gastroptosis,  78,  351 

surgery  of,   280 

symptoms  of,  353 
Gastroscope,   106 
Gelatine,  213 
Glands,  enlarged,  91 
Globus  hystericus,  59 
Glonoin,  '499 
Gluten,  212 

appearances  of,   161 

in  gastric  content,  161 
Glycerine,  use  of,  255 
Glycosuria,  in  gastric  diseases,  54,  299 
Guaiac,  185 
Gurgling,   102,  509 


H 


Habitus   enteropticus    (Stiller),   73 
Hamamelis,   495 
Hand  vibrator,   247 
Headache, 

with  constipation,  408 

with  hypersecretion,  367 
Heart, 

decompensation  of,  51 

incompetency  of,  46 
Heartburn    (pyrosis),   60 

from   hypersecretion,   367 

from  stenosis,  327,  337 
Hematemesis, 

from  cancer.  342 

from  embolism,  501 

from  ulcer,  307,  319 

with  appendicitis,  285 
Hemorrhage,  from  duodenal  ulcer,  483 

from  embolism,  501 

from    hemorrhoids,   492 

from  venous  hyperemia,  491 
Hemorrhoids,   491,   497 

cleansing  of  anus,  494 

injections  of,  479 

operative  treatment  of,  291 

polypi   and  condylomata,   differentia- 
tion of,  493 

result  of  enlarged  prostate,  491 

strangulation,   association   with,   493 

symptoms  of,  492 


Hemorrhoids. — Con  tin  iied. 

tlirombotic  affection,  493 

treatment  of,  493 
Heredity,  influence  of,  49 
Hernia, 

epigastric,  75,  92,  392 

linea  alba,  75,  92 

operation   for,   289 

strangulated,  75 
surgery  of,  290 

umbilical,  75 
Hirshsprung's    disease,    radiogram    of, 

116 
History  of  illness,  47 
Hormonol,   514,   536 
Hourglass  stomach, 

from  ulcer,  310 

lavage  of,   254 

radiogram  of,  110,  111,  124 
Huckleberries,   206 
Hunger  pain,  482 
Hydrastis,   495 

Hydrobilin,   reaction   in   vomitus,   506 
Hydrochloric  acid, 

acid  limits  of,   151 

activation  of  pepsinogen,  36 

bactericide  action  of,  35 

calculation  of  total,   153 

concentration  in  gastric  juice,  35 

detection   and  estimation  of,   146 

estimation  of  deficit,   151,   154 

free  and  combined,   147 

medicinal  use  of,  262 

neutralization  of  by  amino-acids,  148 

quantitative  estimation  of,   149 

relation   to  gastric  cancer,   148 

secretion  of  pyloric  section,  36 

significance  of  absence,   148 

use  of  for  diarrhea,  274 
Hyperacidity,   152 

larvata,  367 
Hyperchlorhydria,  149,  153 
Hj-peremia, 

venous  intestinal,   490 
symptoms  of,  490 
Hyperesthesia, 

celiac  plexus,  28,  81 

ileocolic  plexus,  28,  83 

intestinal,  538 
treatment  of,  538 

significance  of,  81 

zones  of,  83 
Hypermotility, 

of  achylia  gastrica,  374 

of  duodenal  ulcer.  484 
Hypersecretion,  gastric,   141,    152 
neurotic,  366 
of  constipation,   410 
of  duodenal  ulcer,  482 
of  gastric  ulcer,  305,  308 
treatment  of,  367 
Hypersecretion    and    hyperacidity,    re- 
lations of,   153 
Hypertrophy,   gastric,  A'isible,   78 


INDEX 


547 


Hyper  troph  y . — Con  tinu  ed. 

intestinal,  502 
Hypochlorhydria,  149 

symptoms  of,  372 

treatment  of,  372 
Hypochlorhydria  and  achlarhydria,  371 
Hypochondria,   71 
Hysteria,  523 


Ice  water,  evils  of,  55 

Ichthyol,  274 

Ileum,  cancer  of,  524 

strictures  of,   surgical  treatment  of, 

282 
surgery  of,  284 
tuberculous  ulcer  of,  485 
Ileus,  501,  506,  514 
Indicanuria,  487 

in  colon  stenosis,  506 
in  ileal  stenosis,  505 
paralysis  of  intestine,  534 
Indigestion,    gastric     (dvspepsia),    48, 
382 
intestinal,  397,  399,  402 
Infarcts,  499 

hemorrhagic,   507 
Injections,  of  oil,  Fleiner's,  256 

rectal,  255 
Insufficiency,  cardiac,  491 
Intestinal  gravel,   179 
Intestine, 

incised  woimds,  surgery  of,  283 
inflammation  of,  430 
motions  of,  37 
resection  of,  282 
rigidity  of,  79 
stenosis  of,  99 
Intestinal      gastrogenous      indigestion, 
chronic,   399 
blood  in,  400 
gastric   analysis   in,   400 
stool  in,  400 
symptoms  of,   399 
treatment  of,  401 
Intestinal   indigestion, 

from   tuberculosis   and   amyloid    dis- 
~       eases,  427 
Intestinal  indigestion,  acute,  397 
causes  of,  398 
feces  in,  398 
treatment  of,  398 
Intestinal     indigestion,     in     Basedow's 
disease.    426 
treatment  of,   427 
Intestinal      indigestion,      fermentative, 
402 
diagnosis  of,  404 
faulty  starch  digestion  in,  403 
feces  in,   404 
treatment  of,  405 
Intestinal    indigestion,    parasitic,    422 
Intoxication,  acid,  64 


Iodides,  499 
Iodoform,  494 
Ipecac,  460 
Irrigation,  colon,  257 

continuous    (proctoclysis),  259,  512 
Intussusception,  502 
Invagination,  intestinal,  508,  510,  514, 
516 

occlusion  with,  509 

symptoms  of,  508 


Jaundice    (icterus),  308,  341 
Jackson  membrane,   126 
Jejunum,  position  of,  22 


K 


Kidney,  movable,  action  of,  53 
Kinks,  Lane's,   126 
Koumiss  and  Kefir,  203 
Kyphosis,   349 


Lactase,  42 

Lactic  acid,  detection  of,  15/ 
presence  in  gastric  cancer,  342 
significance   of,    158 
Lavage,  gastric,  303,  512 
for  cancer,  346 
for  chronic  ulcer,  319 
for   dilated   stomach,   332 
indications  for,  251 
method  of,  253 
Laxatives,  270 
Leptothrix,   31,   186 

staining  of,  31 
Leucocytes,   in  gastric  content,   161 
Ligament,   gastro-colic,    18 
Linitis  plastica,  328 
Liver,    invasion    of    bv   gastric    cancer, 

341 
Locomotor  ataxia    (see  tabes  dorsalis) 


M 


Magnesium  oxid,  265 
Magnesium  perhydrol,  371 
Malignant  growtlis,    intestinal,    515 

association  with  anemia,  517 

favorite  sites  of,  515 

symptoms  of,  516 
^laltose,  absorption  of,  43 
^lalnutrition,  indol  in,  178 
Massage,   abdominal,   239 

contraindications  to,  240 

mechanical,  246 

method  of,  240 
Mastication,  29,  30 

cause  of  gastric  secretion,  29 
^Mastication,   insufficient,  55 
McBurney  point,  82 


548 


INDEX 


Meat,  209 

amount  of  fat  in,  210 

preserved,   210 
Meat  fibers, 

in  gastric  content,  161 

in  stool,  173 
Megalocolon,   127 

operation  for,  289 
Megalogastria,  324 
Menstruation, 

digestion   during,    199 

influence  of,  49 
Metallic  poisoning,  480 
Metastasis,  in  Douglas'  pouch,  92,  340 

of  navel,  75 
Migraine,  148 
Milk, 

condensed,  202 

in  dietetics,   200 

pasteurization  and  sterilization  of, 
202 

preserved,  202 

sour,  203 
Morphine  and  codeine,  270 
Mouth,  inspection  of,  72 
Mucous  membrane,  fragments  in  wash 

water,  145 
Mucus, 

amount  of,   144 

detection  of  endogenous  and  exo- 
genous, in  gastric  content, 
143 

from  large  intestine,  180 

from  small  intestine,   181 

gastric,  significance  of,  144 

lack  of,  due  to  digestion,   144 

staining  fluid  for,    143 

with  shriveled  cells,   182 
Myasthenia,     gastrica      (atony),     282, 
325 
symptoms  of,  383 
treatment  of,  385 
Myxorrhea  gastrica,  300 


N 


Nausea,  61 

nervous,  treatment  of,  391 

of  pregnancy  and  puberty,  61 
Needle  spray,  231 
Nephritis,  480 

action  of,  52 
Nephroptosis,  356 

degrees  of,   357 

frequency  of,   357 

symptoms  of,  357 
Neuralgia,  intestinal,  539 

treatment  of,   540 
Neurasthenia,  538 

association    with    constipation,    407 

association     with     gastric     neurosis, 
365 
Neurosis,  gastric, 
forms   of,   365 


Neurosis. — Continued. 
intestinal,  529 

association  with  gastric,  529 
Nile  blue  sulphate  stain,   173 
Nutrition,  state  of,  72 
Nuts,  221 
Nut  galls,  powdered,  494 


O 


Obesity,  false  hunger  in,  56 
Obstruction,  intestinal,  414 
Occlusion,  intestinal,  502,  507 
Occult  blood, 

in  stomach,    159  ' 

in   stool,    184 
Occupations,  influence  of,  50 
Oils.  214 
Oil  meal,   179 
Oleomargarine,  214 
Omentum,   18 
Opium,  513 
Orexin,  266 
Orexoids   (Merck),  344 
"Ox  hunger,"  56 

Oxvuris       vermicularis,       threadworm, 
191,  425 


Pain, 

localization  of,  57 

of     abdominal     arteriosclerosis,     59, 
497 

of  appendicitis,  450,  453 

of  atony,  gastric,  384 

of  cancer,  gastric,  338 

of  dilatation  of  the  stomach,  326 

of  duodenal  ulcer,  58,  482 

of  gall  bladder  disease,  58 

of  gall  stones,  59,  64 

of  gastralgia,  59,  392 

of  gastric  neurosis,  59,  378 

of  gastric  ulcer,  58,  306 

of  gastritis,  acute,  296 

of  gastroptosis,  308,  353 

of  globus  hystericus,  59,  376 

of  hernia,  59,  510 

of  hypersecretion,  367 

of  myalgia  of  the  recti,  59 

of  pyloric  spasm,  58,  378 
Palpation,  abdominal,  method  of,  80 
Pancreas,  palpation  of,  87 
Pancreatic  juice,  amount  of,  41 

control  of  by  foods,  41 

enzymes  of,  41 

stimulation  of,  29 
Pancreatitis,  392 
Pankreon,  267 
Papain,  268 
Paraffin,  action  of,  44 
Paralysis,   intestinal,   533 
fecal  vomiting  in,  534 
stimulation  of,  536 
symptoms  of,  533 


INDEX 


549 


Paralysis. — Continued. 
treatment  of,  535 
Parasites,  intestinal,  action  of,  53 
Pelletierine,   424 

Pelvis,  involvement  of  by  cancer,  341 
Pepsin, 

determination  of  presence,   154 

medicinal  use  of,  267 

quantitative   determination   of,    154 
Perforation,   309 
Perigastritis,   278,   310 
Perisigmoiditis,  surgical  treatment  of, 

474 
Peristalsis,   gastric,   32 

control  of  by  drugs,  40 
increase  of,  376 
insufficiency  of,  382 
reversed,   38 
sensations  of,  60 
Peristalsis,     intestinal,     mental     influ- 
ence on,  38 
Peristalsis,       intestinal,       exaggerated, 
532 
symptoms  of,  532 
treatment  of,  532 
Peristalsis,    intestinal,    nervous,    78 
Peritonitis,  507,  510 
Petroleum,  liquid,  272 
Pharyngitis,   cause   of  vomiting,   72 

influence  of,  53 
Pharynx,  examination  of,  72 
Phenacetin,   527 
Phenolphtlialein,  272 
Phenvlendiamine,  185 
Phthisis,  51,  148,  486 
Physostigmine,  514 
Pin  worm,  egg  of,  192 
Pleurisy,  341 
Plexus, 

anastomoses,   28 

celiac,  27 

ileocolic,  28 

mesenteric,  28 

superior  mesenteric,  27 
Pneumonia,  296 
Polypi,   527 

symptoms  of,  528 

treatment  of,  528 
Powders,  baking,  217 
Pregnancy,    491 
Pressure   and   fullness   in   epigastrium, 

57 
Pressure  point,  dorsal,  84,  85 

epigastric,  82 

in  cholelithiasis,  85 

in  gastric  ulcer,  82,  84 

McBurney,   82 
Proctitis, 

complications  of,  477 

detection  by  rectoscope,  476 

diagnosis  of,  478 

feces  in,  476 

gonorrheal,  478 

symptoms  of,  475 


Proctitis. — Continued. 

treatment  of,  478 
Prolapsus,  ani,  478 
Protargol,  479 
Protein,    absorption    and    regeneration 

of,  43 
Proteoses,    detection    and   measurement 

of,   156 
Pseudoangina  pectoris,  diagnosis  of,  53 
Psvchoses,  influence  of,  53 
Ptisans,  217 

Ptomaine  poisoning,  295 
Ptosis, 

colon,  354 

gastric,  351 

renal,  356 
Pus,  free,  significance  of,  183 

in  gastric  content,  162 

in  stool,  182 
Putrefaction, 

agents  of,  44 

intestinal,  201 

products  of,  45 
Pyelitis,  action  of,  52 
Pyloric  stenosis,  309 

stenosis  and  thirst,   56 
Pylorospasm,   377 

symptoms  of,  378 

treatment  of,  378 
Pylorus, 

adhesions  of,  17,  90 
radiogram  of,  116 

control   of,   33 

palpable  contractions  of,  87 

palpation  of,   85 

position  of,   17 
Pyrosis    (heartburn),  60 

from  relaxed  cardia,  61 


R 


Reaction,  diazo,  of  urine,  521 

Reagent, 

Ehrlich  aldehyde,   168 
Guenzburg's,    147  _ 

Toepfer's,    147 
Uffelmann's,   158 

Rectal  pessary,  495 

Rectoscope,   128 

Rectum,  carcinoma  of,  127 
position  and  relations  of,  23 

Regurgitation,  66 

Remedies, 

anti-diarrheal,  272 
secretion   inciting,   262,   265 
secretion  repressing,   265,  268 
stool  producing,   270 

Rennin, 

action  of,  36 

detection   of   presence,   155 
quantitative   determination    of,    155 
significance  of  detection,   155 

Residue,  fasting,   142 

gastric,  layer  arrangement  of,  142 


550 


INDEX 


Resorcinol,  270 
Retention,  minimal,   138 
Rice,  218 
Rigidity,  gastric,  78,  327 

intestinal,  79,  486,  504,  509 
Round   worms,   424 

symptoms  of,  424 
Rumination,  66 


Saccharin,   274 

Salamon  test,   159 

Saliva,  30 

Salvarsan,   323 

Santonin,  424 

Sarcinae,  in  gastric  content,   162 

Sarcoma,  515 

Sclerosis, 

of  abdominal  aorta,  496 

of  mesenteric  arteries,  499 
Scvbala,   palpation   of,   88 
Sea  bathing,  238 
Secretion,  gastric, 

control  of,  268 

excitors  of,  368 

intestinal,  disturbances  of,  537 
Sedatives  and  carminatives,  269 
Sensations,   intestinal,   disturbances  of, 

537 
Sigmoid, 

abnormalities  of,  26 

normal  position  of,  23 
Sigmoiditis, 

colostomy  in,  474 
feces  in,  473 
symptoms  of,  471 
treatment  of,  474 
use  of  rectoscope  in,  473 

chronic,  472 
Sigmoiditis   and  perisigmoiditis,  471 
Silver  nitrate,  321 
Sitz-bath,  231 
Sodium   bicarbonate,   265 
Sounds, 

by  drinking  fluid,   101 

spontaneous,    100 

suecussion,  103 

significance   of,    104 
Sourkrout,  219 
Spasm,  intestinal    (colic),  530 

with  tabes,  530 
Splanchnoptosis,  49 

acquired  form,  348 

air  cushion  for,  362 

congenital,  348 

diagnosis  of,  347 

effects  of  air  cushion,  363 

external    abdominal    appearance    of, 
351 

general  treatment  of,  359 

malnutrition  in,  350 

operative  treatment  of,  358 


Splanchnoptosis. — Continued. 

suspension       by       adhesive      plaster 
(Rose)   method,  361 
Splanchnoptosis    and    gastric    neurosis, 

350 
Sphincter,  anal,  relaxed,  536 
symptoms  of,  536 
treatment  of,  537 
Starch, 

digestion  of,  30 

significance  of  stage  of  digestion  in 

stomach,  156 
stage  of  digestion   in   stomach,   156 
Stasis,   ileal,   radiogram  of,    116 
intestinal,  operation  for,  2^8 
Steapsin, 

detection  of  in  stomach,  156 
gastric,   37 
Stenosis, 

colon,  symptoms  of,  506 

stools  in,  506 
duodenal,  gastric  content  in,  505 
jejunal,   symptoms  of,  506 
ileal,  symptoms  of,  506 
intestinal,  75,  502 

clinical  picture  of,  505 
duration  of,  506 
feces  in,  503 
location  of,  503 
operation  for,  514 
radiogram  of,  117 
sounds  of,    105 
symptoms  of,  502 
treatment  of,  511 
Stomach, 

antrum  activity  of,  32 
attachments  of,   18 
atonic,  x-ray  appearance  of,   107 
axis  of,  19 

borders,   pathological  changes  of,  98 
"crook"  form,   21 
dilated,   radiogram   of,    109 
dilatation     ( ectasia    ventriculi ) ,    324 
causes  of,  326 
of,   intermittent,   328 
of,  medicinal  treatment,  333 
of,   sulfureted  hydrogen,   327 
symptoms  of,  326 
treatment   of,   329 
divisions  and  motility,   31 
fasting,  gastric  juice  in,   141 
forms  of,  96 
fimction  test  of,   164 
"horn"'  form,  20 
hourglass,    99 

radiogram  of,   110,   123 
surgery  of,  280 
inflation  of,  94 
layer  formation  in,  36 
motility  of  by  x-ray,  108 
normal   borders   of.   bv   auscultation, 
103 
borders  of,   by   percussion,   97 
forms  of,  96 


INDEX 


551 


Stomach. — Continued. 

movements  of  with  screen,   106 

position  and  form  of,  18 

prolapsed,   radiogram   of,    109 

radiogram   of,   with   decompensation, 
109 

rigidity  of,  78 

"snail"  form,  radiogram  of,   124 

sounds   of,    100 

surface   anatomy   of,    17 

syphilis  of.  323 

test  of  motility,  138 

tube  shape,   109 

tuberculosis  of,  323 

tumors  of,  89 

upper  and  lower  borders  of,   18 
Stomaeh   tube, 

contraindications,    135 

disinfection  of,   130 

introduction  of,   132 

Jacques,   130 
Stools, 

charcot-Leyden  crystals  in,   179 

cholesterine  crystals   in,    179 

clayey,  significance  of,  170 

consistency  and  form  of,  169 

fattv,   174 

fractional,   169,  517 

meat  fibers  in,  173 

mucus  in,  180 

normal,    microscopic    appearance    of, 
172 

pathologic  connective  tissue  in,  172 

potato  cells  in,   176 

starch  in,  176 

tarry,    171 

tissue  fragments  in,  184 
Strangulation,    intestinal,   508,   510 
Strictures,  esophageal  benign,  275,  276 

malignant,  62,  102,  122 
Strophanthin,  498,  536 
Subacidity,  371 
Succus  entericus,  42 
Sugar,   222 
Sulphur,  494 
Syphilis,  influence  of,  51 


Tabes  dorsalis,  539 
Tamarinden.  466 
Tannalbin,  273 
Tapeworms,  422 

expulsion  of,  423 

svmptoms  of,  423 
Taste, 

disturl)ances  of,  56 

in   chronic   gastritis,   299 

in  gastric  cancer,  339 
Tea  and  coffee,  203 
Teeth,  decayed,  72 

loss  of,  29 
Temperature    {see  fever) 
Tender  points,  localization  of,  83 

searcli  for.  81 


Tenia  saginata,  187 

segments  of,  188 
Tenia  solium,  189 

segments  of,  190 
Tenth  rib,  floating,  73 
Test, 

aloin,  for  blood,  185 

benzidin,  for  blood,  185 

Fuld's,    for    free    hydrochloric    acid, 
103,  164 

Fuld's,    for    determination    of    lower 
gastric  border,  103 

Gross'  for  digestion  of  casein,  179 

Gross'  for  pepsin,  154 

guaiac,  for  blood,   185 

Weber's  for  occult  blood,  184 
Test  breakfast,  30 

Ewald-Boas,   136 
Test  diet,  of  A.  Schmidt,   167 
Test  meals, 

Carlson,   137 

Riegel,   136 
Tetany,  gastric,  327 

cause  of,  56 
Thermophore,  232 
Thirst,  56 
Tincture, 

of  gentian,  266 

of  nux  vomica,  266 

of  opium,  laudanum,  429 
Tissue  fragments,  presence  of,  145 
Tobacco,  use  of,  199 
Tongue. 

coating  constituents,  73 

inspection  of.  72 
Tonicity,   gastric,   325 

impaired,    382 
Tormina  intestinorum,   105 
Toxicity, 

of  atropine,  514 

of  indol,  178 
Traube's   semi-lunar   space,    17 
Treatment, 

Carlsbad,   indications  for,  235 

climatic,  237 

dietetic,  224 

electrical.  247 

sanitarium,  238 

surgical,  indications  for,  275 
Trichinosis  spiralis,  194 
Trypsin, 

in  feces,  174 

in  stomach,  157 
Tryptoplian,  detection  of,  157 
Tubes, 

colon,  257 

double  rectal,  258 

stomach,   131 
Tuberculosis,  intestinal,  485 

association   with   pulmonary,   486 
bacilli   in   stools,  486 
complications  of,  487 
occult  blood  in,  486 
surgical  treatment   of,  489 


552 


INDEX 


Tuberculosis. — Continued. 
symptoms  of,  486 
treatment  of,  488 
Tuberculosis,   pulmonary,   46,   51 
Tumors, 

fecal,  520 

fixation  of,  89 

gastric,  change  of  position,  90 

intestinal,  mobility  of,  93 

palpation  of,  88 

phantom,  76,  89 

respiratory  mobility  of,  89 

tuberculous  ileocecal,  487 
operative  treatment  of,  286 
Tympany, 

of  abdomen,  with  intestinal  strangu- 
lation,  510 

of  stomach,  97 
Typhlatonv,  422 
Typhlitis.  ^422 

association  with  cecum  mobile,  444 

(cecum    mobile),   radiogram   of,   444 

diagnosis  of,  446 

leucocytes  in,  446 

stercoralis,   414 

surgical  treatment  of,  448 

symptoms  of,  443 

treatment   of,   446 
Typhoid  fever,  characteristics  of,  54 

chronic  diarrhea  following,  400 

U 
Ulcer, 

callous,  palpation  of,  91 
chronic  gastric,  313 
duodenal,    481 

complications  of,  484 

occult  blood  in,  483 

radiogram  of,  116,  124,  483 

symptoms  of,  481 

treatment  of,  484 
Ulcer,  gastric,  51 

adhesions  of,   309 

association  with  cancer,  310 

callous,  310 

causation  of,  51 

causes  of,  305 

differentiation     from     cholecystitis 
and  gastroptosis,  308 

dilatation   following,  309 

dorsal  pressure  point,  84 

Fleiner's   treatment,   320 

hemorrhagic    stage,    treatment    of, 
311 

hourglass  stomach  in,  310 

hypersecretion  in,  152,  308 

medicinal  treatment  of,  321 

occult  blood  in.  308 

perforation    of,    309 

periodicity  of,  50 

proof  of  healing,  322 

radiogram  of,   122 

radiographic   detection    of,    110 

results  of  treatment,   323 


Ulcer. — Continued. 

surgical  treatment  of,  279 

symptoms  of,   306 

treatment  of,  310 
Ulcer,  gastro-duodenal,  79 

requiring  surgery,  279 

surgical  treatment  of,  277 
Ulcer,   intestinal,   480 
Ulcer,    duodenal    and   jejunal,    surgery 

of,   282 
Umbilical  glands,  91 
Urethritis,  reflex  action  of,  53 
Urinary   diseases,   52,   299 
Urine,  examination  of,  48,  71 

significance  of,  71 
Uterus,  abnormal,  influence  of,  52 


Vagus  nerve,   28 
Validol,   270 
Varices,  intestinal,  491 
Vegetables, 

leguminous,  218 

root,  218 
Visceral  crises,  497 
Veins, 

gastric,  26 

of  lower  intestinal  tract,  27 

portal,  27 
Volvulus,  508 
Vomiting,   64 

action   of  antrum,   33 

association  with  genital  diseases,  65 

"coffee  grounds,"  338 

juvenile,   64 

nervous,   64,  381 

treatment    of,    382 

of  cerebral  origin,  64 

of  reflex  origin,  65 

periodical,   64 

time  of  after  food,  66 
Vomitus, 

bile  in.  68 

blood   in,   68 

excessive,  significance  of,  67 

mucus  in,  69 

nature  of,  67 

odor  of,  67 

W 

Waters, 

Bedford  Springs,  234 

bitter,  236 

contraindications  to,  237 

carbonated.   200 

Carlsbad,   234 

Congress,  236 

Kissingen,  236 

mineral,  233 

Vichy,  234 
Waterbrash,  65 
Whev,  203 
Wine,  Rhine,  205 


Date  Due 

PHINTCO  IN  U.S.*.                 CAT.    NO.    24     161                   ^ 

»^' 000 


1' 


3 


WI  100 

A935d 

1916 

Austin,  Arthur  E 

Disesises  of  the  digestive 
tract  %,M'    .  .  ; .  . 

WI  100 
A935d 
1916 
Austin,  Arthur  E 

Diseases  of  the  digestive  tract  . . . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


